Getting it right: the impact of a continuing medical education program on hepatitis B knowledge of Australian primary care providers.

INTRODUCTION: In Australia, chronic hepatitis B (CHB) disproportionately affects migrants born in hepatitis B endemic countries, but its detection and management in high risk populations remains suboptimal. We piloted a primary care based program for CHB detection and management in an area of high disease prevalence in Sydney, Australia. Prior to its launch, all local general practitioners were invited to take part in a continuing medical education (CME) program on hepatitis B diagnosis and management. MATERIAL AND METHODS: Preceding each CME activity, participants completed an anonymous survey recording demographic data and hepatitis B knowledge, confidence in CHB management, and preferred CME modalities. We compared knowledge scores of first-time and repeat attendees. RESULTS: Most participants (75%) were males, spoke more than one language with their patients (91%), self-identified as Asian-Australians (91%), and had graduated over 20 years previously (69%). The majority (97%) knew what patient groups require CHB and hepatocellular cancer screening, but fewer (42%-75%) answered hepatitis B management and vaccination questions correctly. Knowledge scores were not significantly improved by seminar attendance and the provision of hepatitis B resources. At baseline, participants were fairly confident about their ability to screen for CHB, provide vaccinations, and manage CHB. This did not change with repeat attendances, and did not correlate with survey outcomes. Large group CMEs were the preferred learning modality. DISCUSSION: Knowledge gaps in hepatitis B diagnosis and management translate into missed opportunities to screen for CHB, to vaccinate those susceptible, and to prevent disease complications. The results suggest that a range of innovative CME programs are required to update general practitioners on the modern management of CHB infection.

Cost of treating chronic hepatitis B: comparison of current treatment guidelines.

AIM: To compare program costs of chronic hepatitis B (CHB) screening and treatment using Australian and other published CHB treatment guidelines. METHODS: Economic modeling demonstrated that in Australia a strategy of hepatocellular cancer (HCC) prevention in patients with CHB is more cost-effective than current standard care, or HCC screening. Based upon this model, we developed the B positive program to optimize CHB management of Australians born in countries of high CHB prevalence. We estimated CHB program costs using the B positive program algorithm and compared them to estimated costs of using the CHB treatment guidelines published by the Asian-Pacific, American and European Associations for the Study of Liver Disease (APASL, AASLD, EASL) and those suggested by an independent United States hepatology panel. We used a Markov model that factored in the costs of CHB screening and treatment, individualized by viral load and alanine aminotransferase levels, and calculated the relative costs of program components. Costs were discounted by 5% and calculated in Australian dollars (AUD). RESULTS: Using the B positive algorithm, total program costs amount to 13,979,224 AUD, or 9634 AUD per patient. The least costly strategy is based upon using the AASLD guidelines, which would cost 34% less than our B positive algorithm. Using the EASL and the United States Expert Group guidelines would increase program costs by 46%. The largest expenditure relates to the cost of drug treatment (66.9% of total program costs). The contribution of CHB surveillance (20.2%) and HCC screening and surveillance (6.6%) is small--and together they represent only approximately a quarter of the total program costs. CONCLUSION: The significant cost variations in CHB screening and treatment using different guidelines are relevant for clinicians and policy makers involved in designing population-based disease control programs.

Cotranslational protein folding and terminus hydrophobicity.

Peptides fold on a time scale that is much smaller than the time required for synthesis, whence all proteins potentially fold cotranslationally to some degree (followed by additional folding events after release from the ribosome). In this paper, in three different ways, we find that cotranslational folding success is associated with higher hydrophobicity at the N-terminus than at the C-terminus. First, we fold simple HP models on a square lattice and observe that HP sequences that fold better cotranslationally than from a fully extended state exhibit a positive difference (N-C) in terminus hydrophobicity. Second, we examine real proteins using a previously established measure of potential cotranslationality known as ALR (Average Logarithmic Ratio of the extent of previous contacts) and again find a correlation with the difference in terminus hydrophobicity. Finally, we use the cotranslational protein structure prediction program SAINT and again find that such an approach to folding is more successful for proteins with higher N-terminus than C-terminus hydrophobicity. All results indicate that cotranslational folding is promoted in part by a hydrophobic start and a less hydrophobic finish to the sequence.