Patients with chronic hepatitis B infection: what is their quality of life?

INTRODUCTION: Hepatitis B (HBV) is endemic in Singapore. This study aimed to determine the quality of life of patients with chronic HBV infection (HBV carriers) on conservative management. They were reviewed in primary care facilities and in a district hospital in Singapore. METHODS: This cross-sectional survey utilised a validated Hepatitis Quality of Life questionnaire, which incorporated the SF-36 health survey, to assess a convenience sample of HBV carriers' quality of life in 14 domains. The mean scores in each domain were determined, with higher scores indicating better health. Wilcoxon-Mann-Whitney test was used in the data analysis to determine statistical significance (p-value is less than 0.05). RESULTS: The mean age of 108 participants was 44.1 (standard deviation 12.5) years. They were predominantly Chinese (90.7 percent), male (58.3 percent) and 50.7 percent of them had family members who were HBV-infected. The latter had higher scores in the hepatitis specific limitation (HLIM) domain. The majority did not have any impaired physical nor mental health. In comparison with the healthy peers in the local population, the Chinese HBV carriers scored significantly lower in the "social functioning" domain (p-value is less than 0.001), regardless of gender. CONCLUSION: The majority of HBV carriers had good physical and mental health. Physicians should recognise the impact of the chronic infection on the social aspects of daily living of the HBV carriers, and such issues should be addressed appropriately to provide better quality care.

What barriers do primary care physicians face in the management of patients with chronic hepatitis B infection in primary care?

INTRODUCTION: Asymptomatic chronic hepatitis B virus (HBV) carriers, followed-up in primary care, present a challenge to primary care physicians as they encounter problems in monitoring this group of patients. The study aims to explore the barriers faced by primary care physicians in the management of patients with chronic hepatitis B infection in primary care. METHODS: Qualitative analysis of eight focus group discussions with 43 primary care physicians in Singapore was conducted. RESULTS: Primary care physicians highlighted the HBV carriers' poor compliance to disease monitoring as a major hurdle, attributing to their lack of understanding of the disease, state of denial, fear of stigmatisation in society, failure to perceive benefits, costs and reluctance of investigations due to physical discomfort. The carriers' health-seeking behaviour, such as doctor hopping and the use of traditional medication, were other barriers. The investigators noted that the physicians placed emphasis on passive disease monitoring, focusing on the investigation results when they reviewed the carriers. They were less proactive in explaining the disease's natural history nor discussing the possibility of definitive anti-viral treatment for suitable carriers. These physicians varied in their approaches in disease monitoring of chronic HBV infection. The fees-for-service healthcare system allowed the carrier to seek consultation from different doctors, which could result in disruption of disease surveillance. This was further compounded by the differential cost of investigations in private practices and government-aided polyclinics. The absence of a national HBV registry and recall system and waiting time for referral to specialist clinics in restructured hospitals, were other barriers. CONCLUSION: The management of HBV carriers in primary care could be enhanced by measures that eliminate the barriers involving the patient, doctor and healthcare system.

A qualitative study of health-seeking behavior of Hepatitis B carriers.

INTRODUCTION: Asymptomatic Hepatitis virus (HBV) carriers are often followed up at primary and secondary care centres in Singapore. Compliance to disease monitoring is perceived to be a barrier in their management. The study used qualitative methods to determine the health-seeking behavior of HBV carriers. Understanding such behavior will enable the attending physicians to optimise their care and promote regular disease surveillance. METHODS: Data were collected from 39 HBV carriers from primary and secondary healthcare centres, with different demographic profiles in eight respective focus group discussions (FGD). A nurse conducted the FGDs using a semi-structured guideline. The qualitative data were analysed using standard content analysis technique. RESULTS: There was evidence of doctor hopping among the HBV carriers in seeking the follow-up of their disease. Cost of review and investigations and preference for specialists' care appeared to be determinants of the sites of disease monitoring. Compliance to follow-up seemed to be sub-optimal, arising from apathy, denial, perceived inconvenience and cost of review. A significant proportion of the carriers had tried alternate therapy, took liver supplements but most found them to be ineffective. Most carriers had adopted healthier lifestyle after their diagnosis with regular exercise, smoking cessation and alcohol abstinence. CONCLUSION: Many HBV carriers' inadequate understanding of the disease resulted in indifferent or inappropriate health-seeking behavior towards their disease management. There is room for health education for these carriers to enhance their awareness of the disease and improve compliance to disease monitoring.

Congenital tracheobiliary fistula.

A case of congenital tracheobiliary fistula with absent common bile duct is reported. The patient presented with repeated aspiration pneumonia, and the diagnosis was established during bronchoscopy. Excision of the fistula and cholecystoduodenostomy were successful. This is the fourth reported case of its type and the first one to survive surgical treatment. The condition is a rare cause of respiratory distress in neonates and should be considered in the differential diagnosis of intractable aspiration pneumonia.

In utero intestinal volvulus presenting as neonatal emergency.

A case of in utero intestinal volvulus with haemoperitoneum, diagnosed prenatally by ultrasonography is reported. The diagnostic technique enables planning and prompt management of acute abdomen.

Empyema of the gallbladder.

There is fairly widespread belief that suppuration superimposed upon acute cholecystitis is a rather uncommon condition. Scanty information on this subject is found in the published literature. No doubt, the scarcity of data further reinforces this clinical impression. Yet, from the few studies available, a surprisingly high incidence (7-11%) is documented. We reviewed 518 patients who underwent emergency cholecystectomy and found 139 cases to have frank pus present within the gallbladder. The clinical presentation is often difficult to distinguish from that of acute cholecystitis but diagnosis is crucial to identify this potentially fatal surgical emergency. There are encouraging reports of specific ultrasonic features which can demonstrate the increased viscosity produced by the purulent and fibrinous content within the gallbladder.