- The document discusses guidelines for screening, assessing, treating, and managing chronic hepatitis B infection. It outlines populations that should be screened, goals and definitions of treatment response, first and second line therapies including tenofovir and entecavir, management of antiviral resistance, and screening for hepatocellular carcinoma.
- Key points covered include screening high-risk populations, treating to suppress HBV DNA and improve liver disease, using pegylated interferon as initial treatment in eligible patients, and treating coinfections like hepatitis C and D.
- Monitoring for treatment response and resistance is important, involving regular HBV DNA testing and considering resistance testing if virologic breakthrough occurs on therapy.
lecture submitted to healthcare workers ( physicians,dentists,nurses,lab.technicians) to explain the best methods to avoid transmission of hepatitis through health practices
lecture submitted to healthcare workers ( physicians,dentists,nurses,lab.technicians) to explain the best methods to avoid transmission of hepatitis through health practices
Hepatitis B infection in Chronic KidneydiseaseAJISH JOHN
Hepatitis B infection is common among CKD patients especially those on dialysis. The various issues regarding its management and approach to renal transplantation
Work-up and management of chronic hepatitis B in non-pregnant adults, especially in a setting with limited resources such as Pakistan's healthcare system.
A power point presentation on Hepatitis C virus on epidemiology, presentation, diagnosis and current treatment strategies we are practicing in BSMMU at a international standerd.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Diagnosis and management of chronic hepatitis b infection(word)
1. DIAGNOSIS AND MANAGEMENT OF CHRONIC HEPATITIS B INFECTION
Presented by: Dr. Himanshu Rana (JR-3)
Moderated by: Dr. S. K. SonkarMD (Assistant Professor)
Screeningpopulation
• Individual fromhigh/intermediateprevalenceareas
• Householdcontacts
• IV drug abusers
• PolygamousorH/O STD
• Men sex withmen
• Inmatesof correctionfacilities
• ChronicallyelevatedALT/AST
• HCV/HIV +ve
• Patientsonhemodialysis
• Pregnancy
• Immunosuppressive therapy
Prevention
• Carriersto be counseledforpreventionof transmission
• HBV negative contactsshouldreceive vaccination
• Pregnancy – Tenofovirin3rd
trimesterif DNA > 107
IU/ml to reduce transmission*
• Newbornstoreceive HBIgandvaccinationatdelivery
• Postvaccinationresponse testing
– Infantsof carrier mothersat 9 to 15 months
– Annually forchronichemodialysispatients
AssessmentofHBV positive subjects
• Primarycare invetigations
– HBeAg/anti HBeAg
– HBV DNA level
– Anti HCV
– Anti HDV
– Anti HIV
– IgG HAV
– ALT/AST/GGT/serumalbumin/total bilirubin/PT/full bloodcounts
• Secondarycare investigations
– Transientelastography
– Liverbiopsy
Goalsof treatment
• Preventionof long-termnegativeclinical outcomes(eg,cirrhosis,HCC,death) bydurable
suppressionof HBV DNA
• Remissionof liverdisease
• Primarytreatmentendpoint
– Sustaineddecrease inserumHBV DNA leveltolow orundetectable
• Secondarytreatmentendpoints
– Decreasedornormalize serumALT
– Induce HBeAglossor seroconversion
– Induce HBsAglossor seroconversion
– Improve liverhistology
2. Management(adults)
Childrenand young people
• DNA levels>2000 IU/ml / abnormal ALT– liverbiopsy*
• Whento start!!!
– DNA levels>2000 IU/ml / abnormal ALT* or
– Significantfibrosisonbiopsy
• METAVIR stage ≥ F2 or
• Ishakstage ≥ 3
• Fibroscanisnot recommendedinchildren
Treatment sequence**
• Peginterferon α-2ainitial treatmentinall*
• TenofovirandEntecavirassecondline inall*
• Prophylaxistobe startedbefore startingimmunosuppressivetherapyandcontinue till 3
monthsaftersero-conversion
* Exceptinpregnancy,breastfeeding,decompensatedchronicliverdisease
** NICEclinical guidelines,The GuidelinesManual,June 2013; 9-10
• Telbivudine &Adefovirnotrecommended
• If alreadyon Adefovir– continue aspertreatingphysician
• If alreadyon Telbivudinechange to
– Entecavirfor-ve h/o lamivudine resistance
– Tenofovirfor+ve h/oof lamivudine resistance
Whento ConsiderPegIFN?
• Favorable predictorsof response[1,2]
– Low HBV DNA
3. – HighALT
– Genotype A or B > C or D[3-5]
• Specificpatientdemographics[1,2]
– Generallyyoungpeople
– Absence of comorbidities
• Patientpreference[1,2]
• ConcomitantHCV infection
DefinitionofResponse to Antiviral Therapy
Response Definition
Primary nonresponse* ↓ inserum HBV DNA by < 2 log10 IU/mL after≥ 24 wks of therapy
Biochemical response ↓ inserum ALT to withinthe normal range
Virologicresponse
↓ inserum HBV DNA to undetectable levelsbyPCRand
loss ofHBeAg in patients who were initiallyHBeAgpositive
Virologicrelapse
↑ inserum HBV DNA of1 log10 IU/mL after discontinuationof
treatment in≥ 2 determinations> 4 wks apart
Histologicresponse
↓ inhistologyactivity indexby ≥ 2 pointsand
no worseningof fibrosisscore compared to pretreatmentliverbiopsy
Complete response Fulfill criteriaof biochemical and virologicresponse and HBsAg loss
First Line therapy
Decompensatedliverdisease
4. • HepatitisB+C co infection→ Peg IFN+ Ribavirin
• HepatitisB+D co infection→ PegIFN for 48 weeks → Continue treatment& evaluate
response annually
(considerstoppingtreatment ifno↓ inHDV RNA after 24 – 48weeks)
Managementof PatientsWithHIV Coinfection
• HBV/HIV-coinfectedpatientswhorequire HBV therapyshouldbe treated[1]
– Liverbiopsyshouldbe consideredinpatientswith fluctuatingormildlyelevatedALT
(1-2 x normal)
Not on HAART or not Anticipated
to Antiretroviral Therapy*
PlanningAntiretroviral
Therapy (HBV+HIV)
AlreadyReceivingAntiretroviral
Therapy
Antiviral therapythatdoesnot
target HIV,eg:pegIFN or ADV
or entacavir
Althoughtelbivudinedoesnot
target HIV, shouldnotbe used
That are effectiveagainst
bothviruses:( TDF+ LAM)
0R (Emtricitabine+TDF)
preffered
If regimendoesnotinclude drug
active againstHBV,may be treated
withpegIFN, ADV orentacavir.
If LAM resistance,addTDFor
adefovir
Childrenand young people
2nd
line therapy
5. Prophylaxisin immunosupressive therapy
PRE-EXPOSURE PROPHYLAXIS
RecombivaxHB Dose (mcg) Engerix-BDose (mcg)
Infantsandchildren (<11 yearsof age) 0.5 ml (5) 0.5 ml (10)
Adolescents11-19 years 0.5 ml (5) 0.5 ml (10)
Adults>20 years 1.0 ml (10) 1.0 ml (20)
Post-exposure prophylaxsis
• Perinatal exposure of infants: single dose of HBIG,0.5 mL, IMin thigh immediately after
birth,followedbycompletecourse of three injectionsof recombinanthepatitisBvaccine to
be startedwithinfirst12 hours of life.
• Directpercutaneousinoculationortransmucosal exposure toHBsAg-positive bloodorbody
fluids: single IMdose of HBIG, 0.06 mL/kg,as soon as possible, followedbycomplete
course of hepatitisBvaccine withinthe firstweek.
• For those exposedby sexualcontact: single IMdose of HBIG, 0.06 mL/kg,within14 days of
exposure,followedby complete course of hepatitisBvaccine.
6. Managementof Antiviral-ResistantHBV
Treatment Strategy
Lamivudine resistance
Add adefovirortenofovir
Stop lamivudine andswitchtotenofovir/emtricitabine
Adefovirresistance
Add lamivudine
Stop adefovirandswitchtotenofovir/emtricitabine
Switchto or add entecavir
Entecavirresistance Switchto tenofovirortenofovir/emtricitabine
Telbivudine resistance
Add adefovirortenofovir
Stop telbivudineandswitchtotenofovir/emtricitabine
Tenofovirresistance May add entecavir,telbivudine,lamivudine,oremtricitabine
Preventionand Monitoringof Resistance
Prevention
Avoidunnecessarytreatment
Initiate potentantiviral thathaslowrate of drug resistance oruse combinationtherapy
Switchto alternative therapyinpatientswithprimarynonresponse
Monitoring
Testfor serumHBV DNA (PCR) every3-6 mosduringtx
Checkfor medicationcompliance inpatientswithvirologicbreakthrough
Confirmantiviral resistance withgenotypictesting
Screeningfor HCC
• Highrisk to be screenedevery6-12months – USG
• AFP is usedwhere USG isnot available
• HIGH risksubjects
– Asianmenover40 yrs age
– Asianwomenover50 yrs age
– Cirrhotics
– Family historyof HCC
– Africansover20 yrs age
– Anycarrier >40 yrs withDNA >2000 IU/ml or intermittentorpersistentALTelevation
7. Questions
1. Whichof the followingdrugshave beensuggestedasfirstline therapyasperthe EASLD
guidelines2012 for the managementof chronichepatitisB?
a. Tenofovir
b. Adefovir
c. Interferonalpha
d. Peg-IFN alpha
ANS:d
2. Whichof the followingdrugsisan absolute contraindicationforPeg-IFN alphatherapy?
a. Chronicrenal failure
b. Treatedpulmonarytuberculosis
c. Ischemicheartdisease
d. Decompensatedliverdisease
Ans:d
3. Whichof the followingrelatedtohepatitisBinfectionistrue?
a. Around99% cases of infectionresolve afteranepisodeof acute hepatitis
b. NewborntoHBsAgpositive mothersdeveloplife threateningfulminanthepatitis
c. IgMantiHBc is alwaysnegative inacute reactivationof chronichepatitisBvirus
d. Patienttobe startedon immunosuppressive therapyare notrequiredforscreening
of HepB infection
Ans:c
4. Whichof the followingisfalse?
a. Fibroscanmeasuresthe stiffnessof liverinkilopascals bymeasuringthe shearstress
produced.
b. Fibroscanscores of >11kpa are diagnosticof significantfibrosis
c. Liverbiopsyshouldbe usedinpatientswithscore >11kpafor guidingtherapy.
d. All patientswithchronichepatitisBrelatedliverdisease mustbe subjectedto
fibroscan.
Ans:c
5. Whichof the followingisnotcorrect regardingtreatmentof hepatitisBinfection?
a. Tenofovircanbe usedas 2nd
line treatmentinall chronicHepBinfectionregardless
of HBeAgstatus.
b. Firstline therapyof IFN alphashouldbe usedinall indicatedHeatitisBpatientsfor
at least24 – 48 weeksbefore switchingto2nd
line therapy
c. Tenfovirshouldbe usedinpatientwithhistorypositiveforlamivudineresistance
d. Ribavirin shouldbe addedtoPegIFN alphainpatientswithHepatitisCcoinfectionas
firstline treatment.
Ans:b