Optimisation of hepatocellular carcinoma surveillance in patients with viral hepatitis: a quality improvement study.

BACKGROUND: Surveillance for hepatocellular carcinoma (HCC) with 6-monthly ultrasound is a standard of care for higher-risk patients with viral hepatitis. Adherence to screening guidelines is an important quality indicator in hepatology, but multiple studies have demonstrated poor HCC surveillance practices in real-world settings. AIMS: The aim of this project was to audit and then optimise HCC surveillance of viral hepatitis patients, who fulfilled criteria for screening, associated with a large tertiary hospital. METHODS: Clinical practice improvement principles were utilised. A baseline audit of 22 consecutive viral hepatitis patients was performed. Major barriers preventing adequate surveillance were identified and three interventions to improve adherence to guidelines were introduced. These included: improved doctor education, system redesign and improved patient education. The effects of interventions were measured by serial random audits of patients. A final audit occurred over 3 years after the initial baseline audit. RESULTS: At baseline, 46% and 0% of patients had appropriate surveillance performed during the prior 6 months (one surveillance cycle) and 2 years (four surveillance cycles) respectively. Three years after initiation of these strategies, a final audit revealed 92% (vs 46% at baseline) and 64% (vs 0% at baseline) of patients had appropriate HCC surveillance performed during the preceding 6 months and 2 years intervals respectively (P < 0.001 in each case). CONCLUSIONS: Simple and low-cost interventions can considerably improve the clinical effectiveness of HCC screening programmes in real world settings. Clinical practice improvement principles appear to be a valid methodology for achieving this positive change.

Single centre experience with pegylated interferon and ribavirin for hepatitis C: looking back before moving forward.

BACKGROUND: Hepatitis C treatment is successful in 40-80% of patients in drug sponsored registration trials. However, few studies have examined treatment outcomes in non-trial, routine clinical practice settings. AIM: The aim of this study was to investigate the treatment outcomes and predictors of a sustained virological response in a routine clinical setting. METHODS: Data were collected retrospectively on patients treated for hepatitis C between January 2004 and March 2010 in a tertiary hospital setting. Demographics, treatment outcomes and potential predictors of outcome (viral genotype, viral load, virological response, platelet count, alanine transaminase level, glucose, ferritin, weight, fibrosis and cirrhosis, compliance, dose reductions, adverse events, psychiatric and alcohol history) were recorded. Univariate and multiple logistic regressions were performed. RESULTS: A total of 405 patients was treated during the study period. On an intention to treat basis, sustained virological response rates were 55%, 82% and 72% in genotypes 1, 2 and 3 respectively. Predictors of response were gender, age, genotype, weight, fibrosis, cirrhosis, platelet count and alanine transaminase on univariate analysis. Age, genotype, cirrhosis and platelet count were independently associated with sustained virological response on multiple logistic regression. CONCLUSION: In our cohort, treatment outcomes for genotype 1 and 2 were similar to results from clinical trials but results for genotype 3 were inferior. Clinicians should not assume that results from registration trials are transferable to their own clinical practice. This has particular relevance for the new era of triple therapy regimens containing direct antivirals.

[Epidemiological aspects of spinal diseases in the GDR in 1979 to 1988]. / Epidemiologische Aspekte der Erkrankungen der Wirbelsäule in der DDR im Zeitraum 1979 bis 1988.

The socio-economic impact of disorders of the spine and the back has obtained an increasing importance in all industrial countries. Considering indicators of public health and national economy, namely temporary sickness incapacity for work, invalidity (insured persons in the GDR), utilization of hospital services (total population of the GDR), of rheumatological dispensaries as well as of the general practitioner, frequencies have been studied and trends pursued by means of serial analyses in a 10-year period. Diseases of the spine and the back within diagnostic class XIII/ICD, 9th revision, 1975 (diseases of the musculoskeletal system and connective tissue) have caused--nearly 2/3 of all cases of sickness incapacity for work--1/3 of the incidence of disability pensions--about 1/3 of the utilization of hospital services--about 1/5 of the utilization of rheumatological dispensaries--more than 50% of all cases consulting the general practitioner. As to the indicators sickness incapacity for work, incidence of disability pensions and discharges from the hospital, the serial analyses of the period from 1979 to 1988 have shown that the diseases of the spine and the back have the highest increase within the group of class XIII.

[Outpatient care in uric acid disorders]. / Ein Beitrag zur Dispensairebetreuung der Urikopathie.

In 35 patients with uricopathy (arthritis urica, essential hyperuricaemia) the serum uric acid values, consumption of alcohol, overweight, hypertension and liver enzyma under dietary and medicamentous therapy (allopurinol) were investigated. Here during an observation lasting 12--48 months allopurinol proved as a well tolerable uricostatic drug which was sufficiently effective also with a considerable exogenic purine application. We only insufficiently succeeded in influencing overweight and alcohol consumption as well as hypertension by rheumatic dispensary care and family doctor.

[Classification of rheumatic diseases. Knowledge and problems]. / Klassifikation rheumatischer Erkrankungen. Erkenntnisse und Probleme.

A classification of diseases serves following purposes: --Collection and processing of data on morbidity and mortality (administrative objective) --Tool for diagnostic evaluation (clinical decision making) --Indicator of the scientific state of the art of the disease (theoretic taxonomy). In the efforts to unify the classification of rheumatic disease, following two goals are realistic: 1) Improvement in the effective communication 2) Agreement with the targets set. The International Classification of Diseases for Rheumatology and Orthopedics (ICD-R and O), which has been jointly elaborated by the International League Against Rheumatism (ILAR) and the Societé Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT), is a practicable international standard for the next years.

[Effects of menopause, pregnancies, breast feeding and hormonal contraceptives on the course of rheumatoid arthritis]. / Beeinflussung durch Klimakterium, Schwangerschaften, Stillperioden und Ovulationshemmer.

PIP: Of 763 patients who were treated for rheumatoid arthritis (RA), 219 went through menopause, 114 were pregnant, 92 breast-fed children, and 29 used oral contraceptives. Of the 219 menopausal women, 5% experienced an improvement and 46.1% an adverse effect on the RA. It was found that those who experienced improvement during menopause more often had had RA for longer periods and tended to have developed RA before the 45th year of age. 59 patients first developed RA during the menopause, and a general adverse effect of menopause on RA was observed. Increased seronegativity and a reduction in rheumafactor levels were observed in this group, as well as a significantly higher BSG level. In the group which developed RA during menopause, increases in morphological stage II, in grade I of functional inefficiency, and in grip strength and the BFT were observed. There was also a significant increase in the incidence of long arthralgic periods before developing RA during menopause. The relationship between RA during menopause and various other factors, e.g. occupation, weight, prior therapy, is also discussed. Among the 114 pregnant patients, 42 reported a positive effect and 30 an adverse effect on RA. Among the 92 patients who breast-fed their children, 25 reported an adverse effect and 19 reported improvement of RA. Patients who had had RA for longer periods more often reported improvement during pregnancy and breast feeding. Adverse effects of pregnancy on RA usually continued during the breast feeding period. Of the 29 patients who had used oral contraceptives, 5 reported a positive effect on RA.^ieng