Role of reimbursement and Physicians' awareness in the survival of sorafenib-eligible advanced hepatocellular carcinoma patients.

In 2008, sorafenib became the first approved systemic therapeutic agent for advanced HCC. Although its pharmacological efficacy has been established, reimbursement for such a new, high-cost drug, as well as physicians' awareness and prescription practice, likewise contribute to its clinical effectiveness. We therefore conducted a retrospective study using 38 sorafenib-eligible, advanced HCC patients when sorafenib was approved but not yet reimbursed as a control and 216 patients during the reimbursed era. Study group showed longer survival at 8.2 months versus the control's 4.9 months (p = 0.0063 hazard ratio: 0.612 [0.431 ~ 0.868], p = 0.0059). Among the 42 (19.4%) patients who survived more than 2 years, 50% had tumor rupture, and all 32 patients with portal vein tumor thrombus and/or extrahepatic metastasis received sorafenib (p = 0.003). Furthermore, during their first 2 years of HCC management, sorafenib had been given in 29.1% of the treatment courses among survivors between 2 and 5 years while it was prescribed in 55.8% among the more than 5 years survivor group (p < 0.001). In conclusion, survival of sorafenib-eligible HCC patients significantly improved after reimbursement. Patients who underwent longer sorafenib treatment had a survival advantage, except for those with tumor rupture. Reimbursement and awareness of prescriptions for a newly introduced medication therefore improve clinical effectiveness.

A Cost-Effective and Labor-Saving Method for Detecting Human Leukocyte Antigen B27 Status via Sequence-Encoded Fluorescence Amplification Assay.

Identification of human leukocyte antigen B27 (HLA-B27) by flow cytometry (FCM) has been widely applied in clinical practice for auxiliary diagnosis of ankylosing spondylitis (AS). However, FCM requires freshly prepared samples and relies on expensive equipment, reagents, and an experienced operator. To provide a cheaper and more convenient method for HLA-B27 detection, we proposed a new method termed sequence-encoded fluorescence amplification assay (SEFA), which specially recognized sequences of HLA-B27 gene (HLA-B∗27) covering current common subtypes in a single closed tube. SEFA could detect as low as 10 pg (equal to 3 copies) genomic DNA per reaction and distinguish HLA-B∗27 from other HLA-B alleles with highly similar sequences. A total of 288 clinical samples were tested by SEFA, including 181 patients with AS and 107 healthy controls. Compared with the detection results from FCM, two controversial samples of patients with AS were obtained and further confirmed to be consistent with SEFA by Sanger sequencing, indicating that this method was more accurate than FCM. Moreover, SEFA could detect HLA-B27 status by using supernatant from crude extract of 10-µL blood without commercial reagents. Overall, SEFA has the potential to be an alternative for HLA-B27 identification with the advantage of convenience and low cost, especially suitable for early diagnosis of AS in areas with limited medical resources.

[Assessment of Emission Reduction Potential of CO2 Capture, Geological Utilization, and Storage in Cement Industry of China].

The cement industry faces great pressure from the targets of carbon peak and carbon neutrality. CO2capture, geological utilization, and storage(CCUS) technology is crucial for CO2 mitigation in large-scale fossil-based industries. An integrated techno-economic assessment model of CCUS was improved here to assess the potential of CCUS retrofits in the cement industry in China, and the cost curve or supply curve of CCUS in the cement industry was obtained. The model set up ten scenarios from four aspects:source-sink matching distance, capture rate, CCUS technology, and technical level. The cement enterprise screening, site screening, techno-economic evaluation, and source-sink matching of CCUS were completed to answer some key problems in realizing low-carbon development via CCUS, such as enterprise inventory, storage site, emission reduction scale, and cost range. Under the scenario of 250 km matching distance, 85% net capture rate, CO2-enhanced water recovery technology, and current technical level, 44% of cement enterprises reduced carbon emission via CCUS, the cumulative capacity reached 625 million tons per year, and the levelized cost was 290-1838 yuan·t-1. The projects with a levelized cost of fewer than 600 yuan·t-1 accounted for 77% and could reduce CO2 emission by 564 million tons annually. The projects whose levelized cost was less than 400 yuan·t-1 could reduce CO2 by 199 million tons per year. When the coupling of CO2-enhanced oil recovery and CO2-enhanced water recovery technology was considered, the levelized cost was 27% lower. When the cement capacity was less than 530 million tons per year, the additional cost of cement production was 95-300 yuan·t-1. Under technological progress to 2030, the levelized cost will be reduced by 9%-15%. The regions with early demonstration advantages of full-chain CO2-enhanced water recovery technology were Xinjiang, Inner Mongolia, Ningxia, Henan, and Hebei. Additionally, the areas suitable for cement CCUS cluster included Ordos Basin, Junggar Basin, Bohai Bay Basin, and Songliao Basin. It is technically feasible for the cement industry to deploy full-chain CCUS projects, and low-cost projects have an early demonstration opportunity. These results can provide a quantitative reference for the low-carbon development of the cement industry and the commercial deployment of CCUS in cement production.

Comprehensive Assessment of Exposure Pathways for Perfluoroalkyl Ether Carboxylic Acids (PFECAs) in Residents Near a Fluorochemical Industrial Park: The Unanticipated Role of Cereal Consumption.

With the replacement of perfluorooctanoic acid (PFOA) with perfluorinated ether carboxylic acids (PFECAs), residents living near fluorochemical industrial parks (FIPs) are exposed to various novel PFECAs. Despite expectations of low accumulation, short-chain PFECAs, such as perfluoro-2-methoxyacetic acid (PFMOAA), previously displayed a considerably high body burden, although the main exposure routes and health risks remain uncertain. Here, we explored the distribution of perfluoroalkyl and polyfluoroalkyl substances (PFASs) in diverse environmental media surrounding a FIP in Shandong Province, China. PFECAs were found at elevated concentrations in all tested matrices, including vegetables, cereals, air, and dust. Among residents, 99.3% of the ∑36PFAS exposure, with a 43.9% contribution from PFECAs, was due to gastrointestinal uptake. Dermal and respiratory exposures were negligible at 0.1 and 0.6%, respectively. The estimated daily intake (EDI) of PFMOAA reached 114.0 ng/kg body weight (bw)/day, ranking first among all detected PFECAs. Cereals emerged as the dominant contributor to PFMOAA body burden, representing over 80% of the overall EDI. The median EDI of hexafluoropropylene oxide dimer acid (HFPO-DA) was 17.9 ng/kg bw/day, markedly higher than the USEPA reference doses (3.0 ng/kg bw/day). The absence of established threshold values for other PFECAs constrains a comprehensive risk assessment.

[Analysis of outcome indicators in clinical trials on Chinese medicine as adjuvant therapy for severe pneumonia].

This study analyzed the outcome indicators in randomized controlled trial(RCT) on Chinese medicine as adjuvant therapy for severe pneumonia in the past years, laying a foundation for the design of clinical trials on and construction of core outcome set(COS) for severe pneumonia. To be specific, related RCT was retrieved from CNKI, Wanfang, VIP, SinoMed, PubMed, EMbase, Cochrane Library, Web of Science, Chinese Clinical Trial Registry, and ClinicalTrials.gov(from January 1,2011 to April 9,2022). Then data in the trials were extracted, and the quality of included RCT was assessed according to Cochrane handbook, followed by descriptive analysis of the use of outcome indicators. A total of 11 833 articles were screened out, and finally 34 RCTs were included(2 were protocols). The included trials involved 109 outcome indicators with emergence frequency of 320, which were mainly classified into 9 categories: physicochemical indicators(54, frequency 167), time to achieve the efficacy(15, frequency 38), clinical effective rate(10, frequency 36), quality of life(11, frequency 35), symptoms and signs(7, frequency 18), traditional Chinese medicine(TCM) syndrome(4, frequency 13), safety(3, frequency 8), economic evaluation(1, frequency 1), other indicators(4, frequency 4). The indicators with high frequency followed the order: total effective rate, arterial oxygen partial pressure, C-reactive protein, white blood cell count, arterial blood carbon dioxide partial pressure. A total of 5 articles(14.71%) reported the main outcome indicators and 11 articles(32.35%) adopted the efficacy on TCM syndromes as the outcome indicator. There are many problems in the selection of outcome indicators in RCT on the treatment of severe pneumonia with Chinese medicine, mainly manifested as the disregard of clinical endpoint indicators, the inappropriate selection of surrogate indicators, and the non-standard evaluation criteria for the efficacy on TCM syndrome. It is suggested that the evaluation system for the efficacy of Chinese medicine on severe pneumonia should be established in accordance with the method for international COS to improve the quality of clinical trials.

A Pilot Assessment on the Role of Procalcitonin Dynamic Monitoring in the Early Diagnosis of Infection Post Cardiac Surgery.

Purpose: To evaluate the value of dynamic monitoring of procalcitonin (PCT) as a biomarker for the early diagnosis of postoperative infections in patients undergoing cardiac surgery. Methods: In total, 252 patients who underwent cardiac surgery were retrospectively included. The postoperative patients' PCT level, change value (△PCT), and clearance rate (△PCTc) were compared between the infected and noninfected groups in adult and pediatric patients on postoperative days (PODs) 1, 3, and 5. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the diagnostic value. Results: Procalcitonin concentration decreased progressively in the noninfected group in adult and pediatric patients; PCT concentration continued to rise until it peaked on POD 3 in the infected group. In adult patients, the AUC of PCT for diagnosis of infection on PODs 1, 3, and 5 were 0.626, 0.817, and 0.806, with the optimal cut-off values of 7.35, 3.63, and 1.73 ng/ml, respectively. The diagnostic efficiency of △PCT3 and △PCT C3 was significantly better than △PCT5 and △PCT C5 , respectively. In pediatric patients, the AUC of PCT for diagnosis of infection on PODs 1, 3, and 5 were 0.677, 0.747, and 0.756, respectively, and the optimal cut-off values were 27.62, 26.15, and 10.20 ng/ml. Conclusion: This study showed that dynamic monitoring of PCT levels could be an effective clinical means to help to discover postoperative infection earlier. The PCT level and its change indicators on POD 3 in adult patients and the PCT level on POD 5 in children can indicate infection.

Taiwan accelerates its efforts to eliminate hepatitis C.

The estimated prevalence of anti-HCV was 3.3% (1.8-5.5%) in the general population in Taiwan with several regional disparities. The reactive anti-HCV in different regions may vary between 0% and 65%. The National Hepatitis C Program (NHCP) office estimated approximately 623,323 persons reactive with anti-HCV based on several extensive region- and cohort-wide studies. Taiwan has accelerated its efforts to eliminate hepatitis C since 2018 by committing to achieve World Health Organization (WHO)'s 2030 goal of treating 80% of eligible patients by 2025. Many aggressive measures by the Ministry of Health and Welfare (MOHW) have been ongoing including several key success factors such as political commitment by the MOHW to finance this national program and improve National Health Insurance (NHI) reimbursement restrictions for treatment. Meanwhile, the Taiwan Centers for Disease Control (CDC) instituted harm reduction programs and the Health Promotion Administration (HPA) started to improve awareness and perform national screening programs. The NHCP office instituted monitoring, evaluation, micro-elimination and funding to linkage to care programs. In addition to sustainable financing, it is imperative to scale-up screening coverage through a precision public health approach to fill the gap of under-diagnosis. Hopefully, we can achieve early elimination by announcing the treatment target of 250000 CHC patients by 2025.

Hepatitis C virus core antigen is cost-effective in community-based screening of active hepatitis C infection in Taiwan.

BACKGROUND AND PURPOSE: Hepatitis C virus (HCV) core antigen is highly sensitive and specific in viremic HCV diagnosis. This study evaluated the cost-effectiveness of HCV core antigen (HCVcAg) in community-based screening for active HCV infection. METHODS: Between 2017/07 and 2018/07, community-based screenings for active HCV infection with two-step (anti-HCV for screening and HCVRNA for diagnosis) and one-step processes (HCVcAg for screening and diagnosis) were conducted in two districts in Kaohsiung City. While HCVcAg test was positive at ≥3 fmol/L, the lowest level of HCV-RNA detection was 12 IU/mL. We analyzed the cost-effectiveness of two algorithms in identifying active HCV infection. RESULTS: There were two large-scale screenings using the two-step process with a total of 2452 residents enrolled; while six hundred and forty-four residents participated in continuous small-scale screening with the one-step process. The prevalence of anti-HCV and positive HCVcAg was 3.4% and 2.8%. The viremic rate was 1.4% and 2.8% for two- and one-step processes (p < 0.001). While all positive HCVcAg were viremic, 42.4% of positive anti-HCV patients had viremia. The positive predictive value was 42.2% and 100% for two- and one-step processes in detecting active HCV infection (p < 0.001). In identifying one active HCV infection, the cost was $755.3 and $711.1 dollars for two- and one-step processes respectively. CONCLUSION: Compared to the two-step process in community-based screening, continuous screening with the HCVcAg test as a one-step tool for active HCV infection was cost-effective in areas with low seroprevalence of HCV in Taiwan.

Two-generational reproductive toxicity assessment of 6:2 chlorinated polyfluorinated ether sulfonate (F-53B, a novel alternative to perfluorooctane sulfonate) in zebrafish.

As an alternative to perfluorooctane sulfonate (PFOS), 6:2 chlorinated polyfluorinated ether sulfonate (commercial name: F-53B) has been used in the Chinese chrome plating industry for over four decades. It has been increasingly detected in environmental matrices in recent years, causing great concern regarding its potential health risks to humans and wildlife. However, its adverse effects on biota remain largely unknown. To explore the chronic toxicity of F-53B on reproduction, a two-generational study was conducted using zebrafish (Danio rerio). Adult zebrafish (F0 generation) were chronically exposed to different concentrations of F-53B (0, 5, 50, and 500 µg/L) for 180 d using a flow-through exposure system, with F1 and F2 generations reared without exposure. The reproductive toxicity endpoints were assessed in F0 and F1 adult fish. Results showed that F-53B accumulated in the F0 gonads and transferred to the F1 generation via maternal eggs, and even remained in F1 adult fish and their eggs (F2) after 180 d depuration. In the F0 generation, F-53B exposure significantly inhibited growth and induced reproductive toxicity, including decreased gonadosomatic index and egg production/female, changes in the histological structure of the gonads, and increased serum testosterone levels. In particular, serum estradiol and vitellogenin levels were significantly increased in 5 µg/L F-53B-exposed adult males. The transcriptional levels of several genes along the hypothalamic-pituitary-gonadal axis were altered in F0 generation fish. Testis transcriptome analysis revealed that F-53B exposure disrupted spermatogenesis in F0 male zebrafish. Maternal transfer of F-53B also induced adverse effects on growth and reproduction in the F1 generation. Furthermore, the higher occurrence of malformation and lower survival in F1 and F2 embryos indicated that parental exposure to F-53B could impair the embryonic development of offspring. Taken together, this study demonstrated that F-53B could induce reproductive toxicity in zebrafish similar to that induced by legacy PFOS, and its potential adverse effects on offspring deserve further investigation.

Elevated concentrations of perfluorohexanesulfonate and other per- and polyfluoroalkyl substances in Baiyangdian Lake (China): Source characterization and exposure assessment.

Novel 6:2 chlorinated polyfluorinated ether sulfonate (6:2 Cl-PFESA) and legacy PFASs, such as perfluorohexane sulfonate (PFHxS), have been used to replace perfluorooctane sulfonate (PFOS), a known persistent organic pollutant. Thus, it is critical to understand these PFOS alternatives regarding their sources and concentrations in the natural environment. In this study, 41 surface water samples as well as edible aquatic organisms were collected from Baiyangdian Lake, the largest freshwater lake in Hebei Province, China. Perfluorooctanoate acid (PFOA) and PFHxS were the predominant PFASs detected in the surface water, reaching concentrations of 8 397.23 ng/L and 1 478.03 ng/L, respectively, with PFHxS accounting for the greatest proportion (∼80.00%) in most water samples. PFHxS (mean: 87.53 ng/g) and PFOS (mean: 35.94 ng/g) were also the most prevalent compounds detected in aquatic organisms. Estimated daily intake (EDI) values of PFOS (16.56 ng/kg bw/d) and PFHxS (16.11 ng/kg bw/d) via aquatic food and drinking water were the highest among PFASs, indicating potential exposure risks to residents. In addition, fish product consumption was the important exposure pathway for residents to PFOA, PFHxS, PFOS, and 6:2 chlorinated polyfluorinated ether sulfonate (6:2 Cl-PFESA). This study reports on the highest PFHxS levels ever recorded in surface water, suggesting that further quantification of PFHxS in human serum and assessment of its health risks to local residents are warranted and critical.

Liver stiffness-based score in hepatoma risk assessment for chronic hepatitis C patients after successful antiviral therapy.

BACKGROUND & AIMS: Patients with chronic hepatitis C (CHC) after successful antiviral therapy remain at risk of hepatocellular carcinoma (HCC). This study was to determine whether liver stiffness measurement (LSM) was useful in HCC risk assessment and to develop a risk-score system for clinical use. METHODS: This retrospective study enrolled patients with CHC achieving sustained virological response (SVR) after interferon-based therapy with LSM at/after SVR determination. The demographics, clinical characteristics and HCC development were obtained from medical chart reviews. The diagnosis of HCC was based on recommended criteria. RESULTS: A total of 376 (M/F: 185/191, mean age: 54.1 years) patients, including 278 with pretreatment liver biopsy specimens, with a median follow-up period of 7.6 years were enrolled. Twenty-one patients developed HCC. The 5- and 10-year cumulative HCC incidences were 1.4% and 7.8%, respectively. Multivariate analysis showed advanced fibrosis/cirrhosis, diabetes and LSM were associated with HCC developments with odds ratio (OR) of 12.38, 2.80 and 1.01, respectively. For LSM in HCC prediction, the performance and cut-off were 0.783 and 12 kilopascal (kPa), respectively. For 278 patients with pretreatment biopsy, a risk-score system (score 0-4) combining advanced fibrosis/cirrhosis, diabetes and LSM >12 kPa was developed. With the low-risk group as a reference, patients in intermediate- (OR: 12.57) and high-risk (OR: 197.33) groups carried higher risk of HCC development. CONCLUSIONS: For patients with CHC achieving SVR, liver stiffness value at/after SVR determination was associated with HCC development independently. Patients with pretreatment advanced fibrosis/cirrhosis, diabetes and LSM >12 kPa after SVR were at high risk of HCC development.

Comparison Stratagems of Post-Screening Management of Anti-HCV-Positive Community Residents: Simple Notification, Active Referral, or Accessible Medical Care.

To elucidate the results of post-screening care stratagems for anti-hepatitis C virus (HCV)-positive subjects in the community. Part I methods: The intervention program: A total of 151,790 subjects underwent a large-scale healthcare screening. Subjects aged less than 65 years, with anti-HCV-positive and alanine aminotransferase (ALT) level more than 80 IU/L were followed-up to answer a structured questionnaire. Those responders who met the reimbursement criteria of Taiwan's National Health Insurance for anti-HCV treatment were referred for treatment. Part II: The accessible medical care program: In Yujing township, 271 HCV residents who have been screened before were invited to a bi-weekly hepatitis clinic in Yujing health center. Part-I results: A total of 907 anti-HCV-positive subjects responded and 197(21.7%) were advised the treatment, but only 83(9.2%) did. Finally, 47 patients achieved a sustained virological response (SVR). After this intervention program, 96(10.6%) additional patients were encouraged to be referred, 33(3.6%) received treatment and 20 obtained a SVR. Part II: A total of 140(51.7%) subjects responded and 112 were anti-HCV-positive including 31(27.7%) HCV RNA-negative, 49(43.8%) HCV RNA-positive plus ALT less than 40 IU/L and 32(28.5%) HCV RNA-positive plus ALT more than 40 IU/L. During the follow-up, 14 of 49 patients had ALT more than 40 IU/L. Among 46 eligible HCV patients, 15(32.6%) received treatment and 10 achieved a SVR. Simple notification only made 9.2% of the screened HCV patients treat. Active referral could encourage additional 3.6% to be treated. Additionally, accessible medical care program could result in treatment of 32.6% elderly eligible patients.

Continuation of statin therapy and a decreased risk of atrial fibrillation/flutter in patients with and without chronic kidney disease.

BACKGROUND: To contain cost, Taiwan's previous National Health Insurance Reimbursement Policy requested that physicians discontinue their patients' statin therapy once the serum cholesterol had reached appropriate levels. This allowed us to evaluate the association between statin continuation and the occurrence of atrial fibrillation/flutter and whether it was modified by chronic kidney disease (CKD) status. METHODS: Patients who initiated statin therapy between January 1, 2001 and December 31, 2009 were identified from a random sample of one million subjects in the Taiwan National Health Insurance Research Database. The outcome was atrial fibrillation/flutter. A proportional hazard regression model with time-varying statin use was applied to estimate the hazard ratios (HR) and 95% confidence intervals (CIs) for atrial fibrillation/flutter according to current statin use versus treatment discontinuation, adjusted for baseline disease risk scores and time-varying covariates. RESULTS: A total of 6767 CKD and 63,678 non-CKD patients initiating statin therapy were included and followed for an average of 4.0 years. A total of 1118 participants experienced new-onset atrial fibrillation/flutter. The incidence of atrial fibrillation/flutter was approximately 2 fold higher in the CKD patients. Continuation of statin therapy was associated with a 22% (adjusted hazard ratio 0.78; 95% CI: 0.65-0.93) and 57% (adjusted HR 0.43; 95% CI: 0.27-0.68) decrease in atrial fibrillation/flutter hazard as compared with discontinuation in non-CKD and CKD patients, respectively. CONCLUSIONS: Continuation of statin therapy was associated with a decreased risk of atrial fibrillation/flutter among CKD and non-CKD patients. However, further randomized studies are still needed to assess the association.

[Study on optimal model of hypothetical work injury insurance scheme].

OBJECTIVE: To explore an optimal model of hypothetical work injury insurance scheme, which is in line with the wishes of workers, based on the problems in the implementation of work injury insurance in China and to provide useful information for relevant policy makers. METHODS: Multistage cluster sampling was used to select subjects: first, 9 small, medium, and large enterprises were selected from three cities (counties) in Zhejiang Province, China according to the economic development, transportation, and cooperation; then, 31 workshops were randomly selected from the 9 enterprises. Face-to-face interviews were conducted by trained interviewers using a pre-designed questionnaire among all workers in the 31 workshops. RESULTS: After optimization of hypothetical work injury insurance scheme, the willingness to participate in the scheme increased from 73.87%to 80.96%; the average willingness to pay for the scheme increased from 2.21% (51.77 yuan) to 2.38% of monthly wage (54.93 Yuan); the median willingness to pay for the scheme increased from 1% to 1.2% of monthly wage, but decreased from 35 yuan to 30 yuan. The optimal model of hypothetical work injury insurance scheme covers all national and provincial statutory occupational diseases and work accidents, as well as consultations about occupational diseases. The scheme is supposed to be implemented worldwide by the National Social Security Department, without regional differences. The premium is borne by the state, enterprises, and individuals, and an independent insurance fund is kept in the lifetime personal account for each of insured individuals. The premium is not refunded in any event. Compensation for occupational diseases or work accidents is unrelated to the enterprises of the insured workers but related to the length of insurance. The insurance becomes effective one year after enrollment, while it is put into effect immediately after the occupational disease or accident occurs. CONCLUSION: The optimal model of hypothetical work injury insurance scheme actually realizes cross-regional mobility of workers, minimizes regional differences, and embodies the fairness. The proposed model will, to some extent, protect the rights and interests of enterprises, as well as the healthy rights and interests of workers when they are unemployed.

Report from a Viral Hepatitis Policy Forum on implementing the WHO Framework for Global Action on viral hepatitis in North Asia.

BACKGROUND & AIMS: The World Health Organisation (WHO) Prevention & Control of Viral Hepatitis Infection: Framework for Global Action offers a global vision for the prevention and control of viral hepatitis. In October 2012, the Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP) organised the North Asia Workshop on Viral Hepatitis in Taipei to discuss how to implement the WHO Framework in the North Asia region. This paper presents outcomes from this workshop. METHODS: Twenty-eight representatives from local liver associations, patient organisations, and centres of excellence in Hong Kong, Japan, Korea, and Taiwan participated in the workshop. FINDINGS: Priority areas for action were described along the four axes of the WHO Framework: (1) awareness, advocacy and resources; (2) evidence and data; (3) prevention of transmission; and (4) screening and treatment. Priorities included: axis 1: greater public and professional awareness, particularly among primary care physicians and local advocacy networks. Axis 2: better economic data and identifying barriers to screening and treatment uptake. Axis 3: monitoring of vaccination outcomes and targeted harm reduction strategies. Axis 4: strengthening links between hospitals and primary care providers, and secure funding of screening and treatment, including for hepatocellular carcinoma. CONCLUSIONS: The WHO Framework provides an opportunity to develop comprehensive and cohesive policies in North Asia and the broader region. A partnership between clinical specialists, primary care physicians, policy makers, and people with or at risk of viral hepatitis is essential in shaping future policies.

Liver stiffness measurement as an alternative to fibrotic stage in risk assessment of hepatocellular carcinoma incidence for chronic hepatitis C patients.

BACKGROUND: Hepatic fibrosis stage is useful in assessing risk of hepatocellular carcinoma (HCC) occurrence. AIM: To evaluate liver stiffness measurement (LSM), in addition to fibrosis stage, in risk assessment of long-term HCC occurrence for patients with chronic hepatitis C. PATIENTS AND METHODS: Consecutive patients with chronic hepatitis C, without past history and presence of HCC, with concomitant liver biopsy and LSM were enrolled in this study. All patients attended regular surveillance for HCC development every 3-12 months. The medical records were reviewed. Follow-up LSM was performed at least 1 year later. RESULTS: One hundred and ninety-eight patients (M/F: 112/86) with reliable LSM results were enrolled. Ten patients developed HCC in a median follow-up period of 47.8 months. For patients with initial LSM >24 kPa, 12-24 kPa, and <12 kPa, 5- year HCC incidence was 45.1%, 9.5% and 0.9% respectively. Multivariate analysis showed patients with LSM>24 kPa and patients with LSM 12-24 kPa had higher risks of HCC development (HR: 24.6, CI: 2.7-220.4 and HR:11.7, CI:1.3-105.2). Patients without sustained virological response after treatment also had higher risk of HCC occurrence (HR: 9.7, CI: 1.1-82.2). Among 106 patients with follow-up LSM, there was a higher risk of HCC development for patients with LSM>12 kPa in the initial and follow-up LSM. CONCLUSION: As an alternative of fibrosis stage, initial LSM is useful as a non-invasive method in risk assessment of HCC occurrence for patients with chronic hepatitis C. Serial follow-up LSM>12 kPa carries higher risk of HCC development.

Cost-effectiveness of screening for hepatocellular carcinoma among subjects at different levels of risk.

OBJECTIVE: The American Association for the Study of Liver Diseases 2005 practice guidelines for management of hepatocellular carcinoma (HCC) recommends that various high-risk groups of people undergo HCC surveillance. Our study aimed to investigate whether screening for HCC among subjects with early-stage cirrhosis is more cost-effective than screening among chronic hepatitis B virus (HBV) carriers without cirrhosis. METHOD: Markov-based decision models were constructed to simulate development and progression of cirrhosis and HCC in the following 2 cohorts: subjects with early-stage cirrhosis and subjects who are chronic HBV carriers but do not have cirrhosis. The models also were used to estimate the incremental cost-effectiveness ratio (ICER) for each cohort over a time horizon of 25 years. RESULTS: The average cost per person was less and the average effect was greater for the cohort of chronic HBV carriers without cirrhosis than for the cohort of subjects with cirrhosis. The incremental effects for use of the screening strategy and the non-screening strategy in the 2 cohorts were 0.28 years and 0.86 years, respectively. The ICERs for the 2 cohorts were $25,578 and $15,191, respectively. The cohort of chronic HBV carriers had a greater ICER with respect to the HCC screening programme because of the smaller incremental effect. The sensitivity analyses revealed that HCC incidence and the probability of accidental diagnosis of HCC were critical parameters in the model. CONCLUSION: Screening for HCC among subjects with early-stage cirrhosis is more cost-effective than screening among chronic HBV carriers who do not have cirrhosis.

Liver stiffness measurement in the risk assessment of hepatocellular carcinoma for patients with chronic hepatitis.

BACKGROUND/AIMS: [corrected] The risk of hepatocellular carcinoma (HCC) increased with progression of hepatic fibrosis as assessed by liver stiffness measurement (LSM). This study used LSM to assess the risk of HCC presence in patients with chronic hepatitis. METHODS: The patients with liver tumor or chronic hepatitis indicated for biopsy were prospectively enrolled. LSM was performed on the same day as biopsy. The diagnostic performances of clinical parameters and LSM in predicting HCC presence were compared with the areas under receiver operating characteristics curves (AUROC). The risk of HCC presence was assessed with stratum-specific likelihood ratios (SSLR). The cut-off values and its diagnostic validity were calculated for LSM. RESULTS: A total of 435 patients, including 106 HCC and 329 chronic hepatitis, were enrolled. The AUROC in predicting HCC presence was 0.736, 0.733, 0.594, 0.579 and 0.532 for LSM, alpha-fetoprotein, platelet count, total bilirubin, and aspartate aminotransferase-platelet ratio index, respectively. Multivariate analysis showed liver stiffness was an independent factor for HCC presence (odds ratio 1.07, 95% confidence interval (CI) 1.05-1.09). SSLR for HCC presence by liver stiffness was 0.43 (95% CI 0.32-0.57) in <12 kPa, 1.28 (0.89-1.84) in 12-24 kPa, and 5.94 (3.77-9.35) in >24 kPa. With 12 and 24 kPa as the cut-offs in predicting HCC presence, the sensitivity was 69.8 and 41.5%, respectively. The specificity was 69.6 and 92.7%, respectively. CONCLUSIONS: LSM identified the risk group for HCC presence in chronic hepatitis patients and had high specificity in the prediction of HCC with the cut-off of 24 kPa.

Beta-adrenergic modulation of arrhythmogenesis and identification of targeted sites of antiarrhythmic therapy in Timothy (LQT8) syndrome: a theoretical study.

Timothy syndrome (TS) is a malignant form of congenital long QT syndrome with a mode of arrhythmia onset often triggered by enhanced sympathetic tone. We sought to explore mechanisms by which beta-adrenergic stimulation (BAS) modulates arrhythmogenesis and to identify potential targeted sites of antiarrhythmic therapy in TS. Using a dynamic Luo-Rudy ventricular myocyte model incorporated with detailed intracellular Ca(2+) cycling, along with its one-dimensional multicellular strand, we simulated various clinical scenarios of TS, with stepwise increase in the percentage of G406R Ca(v)1.2 channels from 0 to 11.5 and 23%, and to 38.5 and 77%, respectively, for heterozygous and homozygous states of TS1 and TS2. Progressive prolongation of action potential duration (APD) and QT interval, accompanied by amplification of transmural dispersion of repolarization, steepening of APD restitution, induction of delayed afterdepolariztions (DADs), and both DAD and phase 3 early afterdepolariztion-mediated triggered activities, correlated well with the extent of G406R Ca(v)1.2 channel mutation. BAS amplified transmural dispersion of repolarization, steepened APD restitution, and facilitated inducibility of DAD-mediated triggered activity. Systematic analysis of intracellular Ca(2+) cycling revealed that sarcoplasmic reticulum Ca(2+) ATPase (uptake current) played an essential role in BAS-induced facilitation of DAD-mediated triggered activity and, in addition to L-type calcium current, it could be an effective site of antiarrhythmic therapy under the influence of BAS. Thus G406R Ca(v)1.2 channel mutation confers not only a trigger, but also a substrate for lethal ventricular arrhythmias, which can be exaggerated by BAS. It is suggested that, besides beta-adrenergic blockers and L-type calcium current channel blockers, an agent aimed at reduction of sarcoplasmic reticulum Ca(2+) ATPase uptake current may provide additional antiarrhythmic effect in patients with TS.