1
|
Bätz O, Petroff D, Jedrysiak K, Wolffram I, Berg T, Kramer J, Wiegand J. Successful hepatitis B and C screening in the health check-up in the German primary care setting. JHEP Rep 2024; 6:101122. [PMID: 39188540 PMCID: PMC11345383 DOI: 10.1016/j.jhepr.2024.101122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 08/28/2024] Open
Abstract
Background & Aims A goal of the World Health Organization's global hepatitis strategy is the elimination of chronic hepatitis C virus (HCV) infection by 2030. As part of its strategy, the Federal Joint Committee (Germany) decided to include hepatitis B and C screening in a preventive medical examination, which is performed at the primary care level in Germany. We investigated the results 1 year after implementation of screening between October 2021 and September 2022. Methods HBsAg/HBV DNA and anti-HCV/HCV RNA screenings were identified by billing categories in 286,192 individuals of 11 ambulatory healthcare centers. Results Compared to 30,106 HBsAg and 31,266 anti-HCV laboratory requisitions in the year 2018, the number of tests increased to 286,192 during the screening period. Compared to routine care, additional anti-HCV positive tests age dependently increased the tally by 98% (177 plus 170 positive cases in males) and 123% (96 plus 118 positive cases in females) in those aged 35-44 years up to 518% (17 plus 88 positive cases in males) and 514% (29 plus 149 positive cases in females) in those aged 75-84 years. Similar results were observed for HBsAg. Prevalences of HBsAg, anti-HCV and HCV RNA were 0.54%, 0.79% and 0.13%, respectively. Conclusions A structured hepatitis screening program at the primary care level has been successfully established and leads to age- and-sex-dependent large additional effects compared to routine care. Impact and implications Strategies to eliminate chronic hepatitis B and C virus infection are country specific and vary between clinical scenarios. Our analysis proves the efficacy of a screening program by primary care physicians compared to routine care in a low-prevalence country. This program should be accompanied by additional efforts in risk populations like people who inject drugs who are under-represented in the current screening approach.
Collapse
Affiliation(s)
- Olaf Bätz
- LADR Laboratory Group Dr. Kramer & Colleagues, Geesthacht, Germany
| | - David Petroff
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Katrin Jedrysiak
- LADR Laboratory Group Dr. Kramer & Colleagues, Geesthacht, Germany
| | | | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Centre, Leipzig, Germany
| | - Jan Kramer
- LADR Laboratory Group Dr. Kramer & Colleagues, Geesthacht, Germany
| | - Johannes Wiegand
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Centre, Leipzig, Germany
| |
Collapse
|
2
|
Farooqi WA, AlGubran LM, Abukaram TM, Alharbi LK, Alsanea RA, Zubaidi GA, Alnassr SA, Alaithan TM, Alnamly JM, Altriny QA. Awareness of Hepatitis C Among the General Population of Riyadh, KSA, in 2023: A Cross-Sectional Study. Cureus 2024; 16:e51783. [PMID: 38322064 PMCID: PMC10844775 DOI: 10.7759/cureus.51783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Background Hepatitis C, a highly contagious viral infection transmitted through blood-to-blood contact, poses a significant threat to public health owing to its potential to induce extensive liver damage, leading to the development of life-threatening conditions such as liver cirrhosis and hepatocellular carcinoma, commonly known as liver cancer. Objective This cross-sectional study aims to assess the level of awareness of hepatitis C among the general population in Riyadh, Saudi Arabia. Methodology The study was conducted in Riyadh, Saudi Arabia. A national cross-sectional survey was conducted using a predesigned self-administered validated electronic questionnaire. The questionnaire was distributed electronically to the general population from April to September 2023. Results Out of the 800 participants, most were females (472, 59%), and the largest age group was between 23 and 29 years old (305, 38.1%). Saudi Arabians constituted the highest proportion of participants (609, 76.1%), and most participants were single (437, 54.6%). In terms of occupational status, 288 (36%) worked in occupations not listed. The study found that 463 (57.9%) participants had a low level of awareness about the global prevalence of hepatitis C. Additionally, 489 (61.1%) were aware that hepatitis C can cause both acute and chronic hepatitis, and 441 (55.1%) knew that most infected patients may develop chronic hepatitis. A majority (484, 60.5%) were aware of the importance of washing with soap and water after an accidental needle stick injury. Most participants (574, 71.8%) were aware of the common modes of hepatitis C transmission, such as unsterilized instruments, needle stick injuries, and sharing contaminated needles during drug use. Furthermore, 548 (73%) were aware of the transmission risk through unscreened blood transfusion, and 561 (70.1%) were aware of the higher risk of infection for individuals with multiple sexual partners. Conclusion The study highlights a low level of awareness among participants regarding the treatment and prevention of hepatitis C. To address the low level of awareness regarding the treatment and prevention of hepatitis C, targeted strategies and interventions are needed. This includes the development and implementation of public awareness campaigns, creation of informative educational materials, specialized training programs for healthcare professionals, establishment of support groups and counseling services for individuals living with hepatitis C, and continued support for research efforts and knowledge dissemination. By increasing awareness about hepatitis C, its treatment, and prevention, we can improve outcomes for individuals affected by the disease and reduce its overall burden on communities.
Collapse
Affiliation(s)
- Waqar A Farooqi
- College of Internal Medicine, AlMaarefa University, Riyadh, SAU
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Ohenhen V, Oshomoh SA, Akpojaro E, Enobakhare E, Ovenseri C, Eboreime E. Birth preparedness and complication readiness: Evaluating the "know-do" gap among women receiving antenatal care in Benin City, Nigeria. J Biosoc Sci 2023; 55:1086-1100. [PMID: 36605008 DOI: 10.1017/s0021932022000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Across several African countries, birth preparedness and complication readiness (BPACR) among pregnant women is poor. The practice of BPACR, though improving in recent years, is not commensurate with the knowledge available to pregnant women. Maternal health indices remain sub-optimal. This study evaluates the determinants of this "know-do' gap among women receiving antenatal care at a secondary health facility in Benin City, Nigeria. A cross-sectional study involving 427 pregnant women was conducted between October and December 2020 using a structured interviewer-administered questionnaire. The prevalence of knowledge and practice were described, and the determinants of BPACR practice evaluated using bivariable (chi-square) analysis and multivariable ordinal logistic regression with post-estimation predictive margins analysis. About 77% of respondents had good birth preparedness practice. Multivariable regression revealed that respondents with poor knowledge and moderate knowledge of components of BPACR had statistically significant lower odds (OR:0.05 (95% CI: 0.02-0.13) and 0.10 (95% CI: 0.03-0.30) times, respectively) for greater practice of BPACR when compared to those with good knowledge. Respondents with poor knowledge of danger signs had statistically significant lower odds (OR: 0.08 (95% CI: 0.03-0.26) for greater practice of BPACR when compared to those with good knowledge. But predictive margins analyses demonstrates that knowledge, though critical to practice, is insufficient to optimize practice. The optimum number of danger signs women need to know to improve practice may be between eight to ten. Beyond this number, practice may not change significantly. Other predictors of BPACR practice include income level, parity, gravidity, and residential settings. The number of antenatal clinic visits had no statistically significant correlation with BPACR practice. Interventions to facilitate practice at the community level may be helpful to improve outcomes and bridge the know-do gap with respect to BPACR within the study context.
Collapse
Affiliation(s)
- Victor Ohenhen
- Department of Obstetrics and Gynaecology, Central Hospital, Benin City, Nigeria
| | | | - Ejovi Akpojaro
- Department of General Studies, Edo State College of Nursing Sciences
| | - Egbe Enobakhare
- Department of Family Medicine, Central Hospital, Benin City, Nigeria
| | | | - Ejemai Eboreime
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
4
|
Wolfe HL, Hughto JMW, Quint M, Hashemi L, Hughes LD. Hepatitis C Virus Testing and Care Cascade Among Transgender and Gender Diverse Individuals. Am J Prev Med 2023; 64:695-703. [PMID: 36759228 PMCID: PMC10121731 DOI: 10.1016/j.amepre.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Hepatitis C virus (HCV) prevalence among transgender and gender-diverse individuals ranges from 1.8% to 15.7% versus 1% in the general population. Previous HCV studies inclusive of transgender and gender-diverse individuals primarily rely on convenience-based sampling methods or are geographically restricted. The purpose of this study is to compare the prevalence of HCV diagnoses, testing, and care engagement between transgender and gender-diverse and cisgender individuals. METHODS Using Optum's de-identified Clinformatics® Data Mart Database, in 2022, the unadjusted prevalence of HCV testing among all adults and people who inject drugs from January 2001 to December 2019 was measured. Multivariable logistic regression was used to compare the adjusted odds of HCV diagnoses and care engagement by gender subgroup. RESULTS The overall unadjusted frequency of HCV diagnoses among transgender and gender-diverse individuals was approximately 3 times that of cisgender individuals (1.06% vs 0.38%, p<0.001), including among people who inject drugs (6.36% vs 2.36%, p=0.007). Compared with cisgender women, transfeminine/nonbinary individuals had over 5 times the adjusted odds of a HCV diagnosis and approximately 3.5 times the odds of being tested for HCV. In addition, compared with cisgender women, transfeminine/nonbinary individuals had significantly increased odds of having a HCV‒related procedure (e.g., abdominal ultrasounds, liver biopsies, Fibroscans). Cisgender men had significantly increased odds of receiving HCV medication compared with cisgender women. CONCLUSIONS Although testing was higher among transgender and gender-diverse individuals, the higher overall frequency of HCV diagnoses among transgender and gender-diverse than among cisgender individuals signals persistent health disparities. Interventions are warranted to prevent HCV and increase ongoing testing and treatment uptake among transgender and gender-diverse populations.
Collapse
Affiliation(s)
- Hill L Wolfe
- Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, Massachussetts.
| | - Jaclyn M W Hughto
- Center for Health Promotion and Health Equity, School of Public Health, Brown University, Providence, Rhode Island; Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island; Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island; The Fenway Institute, Fenway Health, Boston, Massachussetts
| | - Meg Quint
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachussetts
| | - Leila Hashemi
- Division of Primary Care, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Landon D Hughes
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan; Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
5
|
Evon DM, Hurt CB, Carpenter DM, Rhea SK, Hennessy CM, Zule WA. Substance Use Disorder Treatment Providers' Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina. RURAL MENTAL HEALTH 2022; 46:162-173. [PMID: 35967261 PMCID: PMC9371459 DOI: 10.1037/rmh0000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers' attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.
Collapse
Affiliation(s)
- Donna M. Evon
- Division of Gastroenterology & Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christopher B. Hurt
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Delesha M. Carpenter
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | |
Collapse
|
6
|
Flores BE, Fernandez AA, Wang CP, Bobadilla R, Hernandez L, Jain MK, Turner BJ. Educating Primary Care Providers and Associate Care Providers About Hepatitis C Screening of Baby Boomers: a Multi-practice Study. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:217-223. [PMID: 32588350 DOI: 10.1007/s13187-020-01805-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Chronic hepatitis C virus (HCV) increases the risk for hepatocellular carcinoma. Despite higher prevalence of HCV in persons born 1945-1965 (baby boomer), screening has not been widely adopted. Both primary care providers (PCPs) and associate care providers (ACPs) need to be educated about the rationale and methods to screen for HCV. In five Federally Qualified Health Centers serving low-income Hispanic communities, PCPs and ACPs attended a 50-min training lecture about HCV epidemiology, screening methods, and evaluation. Using a 12-item questionnaire, knowledge and attitudes were compared for PCPs and ACPs at baseline (pre-test) and following training (post-test). A higher proportion of PCPs correctly answered 3 of 6 knowledge questions on both pre-test and post-test but ACPs' showed more improvement in knowledge (all P < 0.05). ACPs had more favorable attitudes about linking patients to care on pre- and post-tests than PCPs, and ACPs' attitudes improved on all 6 items versus 4 for PCPs. Both PCPs and ACPs improved knowledge and attitudes after training about HCV screening but ACPs had more favorable attitudes than PCPs. Engaging the entire primary care practice team in learning about HCV screening promotes knowledge and attitudes necessary for successful implementation.
Collapse
Affiliation(s)
- Bertha E Flores
- School of Nursing, UT Health San Antonio, San Antonio, TX, 78229-3900, USA
| | - Andrea A Fernandez
- School of Nursing, UT Health San Antonio, San Antonio, TX, 78229-3900, USA
| | - Chen-Pin Wang
- Population Health, UT Health San Antonio, San Antonio, TX, USA
- Center for Research to Advance Community Health (ReACH), UT Health San Antonio, San Antonio, TX, USA
| | - Raudel Bobadilla
- Center for Research to Advance Community Health (ReACH), UT Health San Antonio, San Antonio, TX, USA
| | - Ludivina Hernandez
- Center for Research to Advance Community Health (ReACH), UT Health San Antonio, San Antonio, TX, USA
| | | | - Barbara J Turner
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Dr IRD 322, Los Angeles, CA, 91202, USA.
| |
Collapse
|
7
|
Wyatt B, Perumalswami PV, Mageras A, Miller M, Harty A, Ma N, Bowman CA, Collado F, Jeon J, Paulino L, Dinani A, Dieterich D, Li L, Vandromme M, Branch AD. A Digital Case-Finding Algorithm for Diagnosed but Untreated Hepatitis C: A Tool for Increasing Linkage to Treatment and Cure. Hepatology 2021; 74:2974-2987. [PMID: 34333777 PMCID: PMC9299620 DOI: 10.1002/hep.32086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/29/2021] [Accepted: 07/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Although chronic HCV infection increases mortality, thousands of patients remain diagnosed-but-untreated (DBU). We aimed to (1) develop a DBU phenotyping algorithm, (2) use it to facilitate case finding and linkage to care, and (3) identify barriers to successful treatment. APPROACH AND RESULTS We developed a phenotyping algorithm using Java and SQL and applied it to ~2.5 million EPIC electronic medical records (EMRs; data entered January 2003 to December 2017). Approximately 72,000 EMRs contained an HCV International Classification of Diseases code and/or diagnostic test. The algorithm classified 10,614 cases as DBU (HCV-RNA positive and alive). Its positive and negative predictive values were 88% and 97%, respectively, as determined by manual review of 500 EMRs randomly selected from the ~72,000. Navigators reviewed the charts of 6,187 algorithm-defined DBUs and they attempted to contact potential treatment candidates by phone. By June 2020, 30% (n = 1,862) had completed an HCV-related appointment. Outcomes analysis revealed that DBU patients enrolled in our care coordination program were more likely to complete treatment (72% [n = 219] vs. 54% [n = 256]; P < 0.001) and to have a verified sustained virological response (67% vs. 46%; P < 0.001) than other patients. Forty-eight percent (n = 2,992) of DBU patients could not be reached by phone, which was a major barrier to engagement. Nearly half of these patients had Fibrosis-4 scores ≥ 2.67, indicating significant fibrosis. Multivariable logistic regression showed that DBUs who could not be contacted were less likely to have private insurance than those who could (18% vs. 50%; P < 0.001). CONCLUSIONS The digital DBU case-finding algorithm efficiently identified potential HCV treatment candidates, freeing resources for navigation and coordination. The algorithm is portable and accelerated HCV elimination when incorporated in our comprehensive program.
Collapse
Affiliation(s)
- Brooke Wyatt
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Ponni V. Perumalswami
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY,Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI,Gastroenterology SectionVeterans AffairsAnn Arbor Healthcare SystemAnn ArborMI
| | - Anna Mageras
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Mark Miller
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Alyson Harty
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Ning Ma
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Chip A. Bowman
- Department of MedicineIcahn School of Medicine Mount SinaiNew YorkNY
| | - Francina Collado
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Jihae Jeon
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Lismeiry Paulino
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Amreen Dinani
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Douglas Dieterich
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Li Li
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Maxence Vandromme
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| | - Andrea D. Branch
- Division of Liver DiseasesIcahn School of Medicine Mount SinaiNew YorkNY
| |
Collapse
|
8
|
Physician awareness of hepatitis C virus among different departments. Clin Exp Hepatol 2021; 6:354-358. [PMID: 33511284 PMCID: PMC7816635 DOI: 10.5114/ceh.2020.102155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/19/2020] [Indexed: 02/02/2023] Open
Abstract
Aim of the study To determine the anti-hepatitis C virus (HCV) positivity in our region and to evaluate physician awareness of HCV among different inpatient and outpatient departments in a tertiary reference center in Turkey. Material and methods This retrospective study was conducted between January 2017 and January 2020. The patients tested for anti-HCV for any reason were enrolled from the data of all patients admitted to our hospital, which is the reference center of the region. Results A total of 121,492 anti-HCV assays were screened from the computerized database. Total number of patients with a positive anti-HCV result was 891 (0.81%). HCV RNA was positive in 147 (16.5%) of 891 patients and negative in 389 (43.7%) patients. Unfortunately HCV RNA was not tested in 355 (39.8%) patients. The percentages of the untested patients regarding the departments were 65.38% (n = 85/130) in medical inpatient clinics, 61.02% (n = 72/118) in surgical clinics, 16.67% (n = 88/528) medical outpatient departments, 96.8% (n = 91/94) in surgical outpatient departments, and 90.5% (n = 19/21) in the emergency department. Conclusions The prevalence of anti-HCV positivity was found to be 0.81% and was stable in Turkey. However, the level of physician awareness for HCV was unsatisfactory, and differed between departments. Because HCV is commonly asymptomatic, positive patients should not be overlooked and adequate treatment should be administered. Awareness of physicians should be increased to prevent delays in the diagnosis of hepatitis C and to reduce the number of untreated patients.
Collapse
|
9
|
Del Pino Bellido P, Guerra Veloz MF, Cordero Ruíz P, Bellido Muñoz F, Vega Rodriguez F, Caunedo Álvarez Á, Carmona Soria I. CHRONIC HEPATITIS C PATIENTS LOST IN THE SYSTEM: PREDICTIVE FACTORS OF NON-REFERRAL OR LOSS OF FOLLOW UP TO HEPATOLOGY UNITS. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:833-839. [PMID: 33393328 DOI: 10.17235/reed.2020.7573/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Several barriers remain in the hepatitis C care cascade, which need to be removed in order to eliminate Chronic Hepatitis C. These barriers include deficiencies in screening and confirmatory diagnosis as well as difficulties in accessing treatment. AIMS To identify factors associated with the non-referral of patients with positive HCV-antibody and to identify factors associated with loss of follow-up or non-attendance of these patients to specialist consultation after their referral. METHODS Observational and retrospective single-centre-study, including all positive HCV serologies performed between January 2013 and May 2018 in the Virgen Macarena health area before implementing the one-step diagnosis. Non-referred patients and patients who were lost to follow-up after being referred were identified. RESULTS A total of 54 (77.4%) patients diagnosed in PC and 54 (22.2%) from hospital specialists were not referred (p <0.001). Predictors for non-referral were: stay in prison/ institutionalized (p = 0.04), suffering COPD (p = 0.07), a normal AST value (p = 0.034) or test requested by PCP (p = 0.004). Patients referred from PC were more likely to be lost to follow-up than those referred from hospital specialists (p <0.001). Predictors for loss of follow-up included: opioid replacement therapy (p = 0.034), absence of high blood pressure (p = 0.039) and test requested by PCP (p = 0.049). CONCLUSIONS A high percentage of patients with positive HCV serology were not referred or lost follow-up, mainly those belonging to high risk social groups or those with associated comorbidities. Patients with average values of transaminases or those diagnosed in primary care were also less referred.
Collapse
|
10
|
Allison WE, Choi AN, Kawasaki K, Melhado TV. Evaluating the Effectiveness of the AIDS Education and Training Center (AETC) National Human Immunodeficiency Virus/Hepatitis C Virus (HCV) Curriculum. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2021; 8:23821205211041178. [PMID: 34621993 PMCID: PMC8491153 DOI: 10.1177/23821205211041178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND People with human immunodeficiency virus (PWHIV) who have hepatitis C virus (HCV) coinfection are at a higher risk of progression of liver disease than the general population. Direct acting antivirals provide a therapeutic option for HCV cure, however access to HCV specific care for PWHIV can be challenging. A paucity of specialist providers is a barrier to this care. OBJECTIVES This study aims to assess knowledge gained about HIV/HCV coinfection among health care providers. METHODS AIDS Education Training Centers (AETC) have developed a modular national HIV/HCV coinfection curriculum consisting of a free selfdirected online curriculum to educate health care providers, including nonspecialist providers, involved in the care of PWHIV on HCV care and management. The effectiveness of this curriculum was evaluated with pre and post module assessment completion by learners compared with a paired t-test. RESULTS 716 people received links to the curriculum and 277 modules were completed by 221 unique individuals. 86% completed one module, 9% complete 2 modules, and the remaining 5% completed between 3 and all 6 modules. There were statistically significant increases in knowledge in the epidemiology module.
Collapse
Affiliation(s)
- Waridibo E Allison
- Waridibo Allison, University of Texas
Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7881, San
Antonio, TX 78229, USA.
| | | | | | | |
Collapse
|
11
|
Screening, Linkage to Care and Treatment of Hepatitis C Infection in Primary Care Setting in the South of Italy. Life (Basel) 2020; 10:life10120359. [PMID: 33352991 PMCID: PMC7766029 DOI: 10.3390/life10120359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/09/2022] Open
Abstract
Hepatitis C virus (HCV) infection remains a pressing public health issue. Our aim is to assess the linkage to care of patients with HCV diagnosis and to support the proactive case-finding of new HCV-infected patients in an Italian primary care setting. This was a retrospective cohort study of 44 general practitioners (GPs) who managed 63,955 inhabitants in the Campania region. Adults with already known HCV diagnosis or those with HCV high-risk profile at June 2019 were identified and reviewed by GPs to identify newly diagnosed of HCV and to assess the linkage to care and treatment for the HCV patients. Overall, 698 HCV patients were identified, 596 with already known HCV diagnosis and 102 identified by testing the high-risk group (2614 subjects). The 38.8% were already treated with direct-acting antivirals, 18.9% were referred to the specialist center and 42.3% were not sent to specialist care for treatment. Similar proportions were found for patients with an already known HCV diagnosis and those newly diagnosed. Given that the HCV infection is often silent, case-finding needs to be proactive and based on risk information. Our findings suggested that there needs to be greater outreach, awareness and education among GPs in order to enhance HCV testing, linkage to care and treatment.
Collapse
|
12
|
Coppock D, Chou E, Gracely E, Gross R, Heun-Lee D. Hepatitis C antibody screening and determinants of initial and duplicate screening in the baby boomer patients of six urban primary care clinics. PLoS One 2020; 15:e0235778. [PMID: 32645083 PMCID: PMC7347094 DOI: 10.1371/journal.pone.0235778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 06/22/2020] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION In 2012, the Centers for Disease Control and Prevention released updated guidelines recommending universal, one-time hepatitis C virus screening for all individuals born between 1945 and 1965. Prior to the implementation of these guidelines, testing rates were inappropriately low, but unnecessary duplicate antibody testing was also problematic. In the era of increased efforts to screen "baby boomers", the prevalence and social determinants of initial and duplicate hepatitis C testing have not been well described. METHODS A hepatitis C screening program was implemented at six urban primary care clinics affiliated with Drexel University College of Medicine. Data was collected regarding the screening patterns in these clinics. Annual screening rates for the program were assessed. Multivariate logistic regression analyses were used to examine the association of demographic variables and the outcomes of subjects having ever been tested and subjects having received duplicate testing. RESULTS Following the implementation of the program, the screening rate increased from 16% in the first year of analysis to 82% in the final year of analysis. Of the 6,717 patients screened, 1,207 had duplicate testing, of which 14% had inappropriate duplicate antibody screening. African Americans and Asian patients had a higher odds of being screened. Patients with public insurance had a higher odds of duplicate screening. CONCLUSIONS In the setting of an aggressive hepatitis C screening program, high testing rates may be attained in a target population. However, inappropriate duplicate antibody testing rates may be high, which may be a burden in resource-limited settings.
Collapse
Affiliation(s)
- Dagan Coppock
- Department of Medicine, Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Edgar Chou
- Department of Medicine, Division of General Internal Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Edward Gracely
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, United States of America
| | - Robert Gross
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Dong Heun-Lee
- Department of Medicine, Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States of America
| |
Collapse
|
13
|
Şahin AR, Erdoğan A, Gisi K, İspiroğlu M, Ateş S, Okyay RA, Nazik S, Kantarçeken B. Can family physicians have a role in eradication of hepatitis c infection? TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:393-399. [PMID: 32519959 DOI: 10.5152/tjg.2020.19913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND/AIMS Hepatitis C Virus (HCV) infection is an important global public health problem. The application of screening programs is important for the elimination of HCV in addition to DAA therapies. The aim of this study was to measure the knowledge, attitudes and behaviours of family physicians, who are important in screening programs for the diagnosis, natural history, and treatment of HCV infection. MATERIALS AND METHODS This cross-sectional study aimed to measure the knowledge levels in respect of HCV screening, diagnosis, natural history and treatment, of family physicians working nationwide in Turkey, through a survey. RESULTS The most common reason to perform an anti-HCV test stated by 70.9% (n:420) of the participants was the mandatory screening program before marriage. Of the participants included in the study, 29.6% (n=175) had encountered anti-HCV test positivity at least once within the last year, and of these, 15.4% (n=27) had no knowledge of whether the patient went to a higher level center for further diagnosis, while 58.9% (n=103) did not know the disease stage. In response to questions about current drug options for hepatitis C infection, 14.5% were aware of DAA and 34.8% of participitant reported interferon+ ribavirin. CONCLUSION Family physicians have gaps in their knowledge of the screening, natural history and treatment of HCV infection. The results of this study show that HCV training plans for family physicians should cover all aspects of the infection, and emphasize the necessity for the establishment of guideline-based screening recommendations.
Collapse
Affiliation(s)
- Ahmet Rıza Şahin
- Department of Infectious Diseases and Clinical Microbiology, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Ayşegül Erdoğan
- Department of Public Health, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Kadir Gisi
- Department of Gastroenterology, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaras, Turkey
| | - Murat İspiroğlu
- Department of Gastroenterology, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaras, Turkey
| | - Selma Ateş
- Department of Infectious Diseases and Clinical Microbiology, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Ramazan Azim Okyay
- Department of Public Health, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Selçuk Nazik
- Department of Infectious Diseases and Clinical Microbiology, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Bülent Kantarçeken
- Department of Gastroenterology, Kahramanmaraş Sütçü İmam University School of Medicine, Kahramanmaras, Turkey
| |
Collapse
|
14
|
Dore GJ, Matthews GV. Universal screening for hepatitis C virus infection should be linked to universal treatment access. Nat Rev Gastroenterol Hepatol 2020; 17:321-322. [PMID: 32350442 DOI: 10.1038/s41575-020-0306-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Gregory J Dore
- The Kirby Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Gail V Matthews
- The Kirby Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia.
| |
Collapse
|
15
|
Akkuzu MZ, Sezgin O, Yaraş S, Özdoğan O, Yılmaz İ, Üçbilek E, Ateş F, Altıntaş E. Patients Lost after Anti-HCV-Positive Finding in a Tertiary Care University Hospital: Increased Awareness and Action is Necessary to Eradicate HCV. SISLI ETFAL HASTANESI TIP BULTENI 2019; 53:366-370. [PMID: 32377110 PMCID: PMC7192297 DOI: 10.14744/semb.2019.46656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/29/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Though there is a global effort to eradicate hepatitis C infection (HCV), several obstacles remain. Many patients infected with the virus are not detected or go untreated. The goal of this study was to identify any barriers to treatment and any difficulties contributing to the elimination of HCV infection at a tertiary care university hospital. METHODS This was a retrospective review. The hospital data system was searched for records of patients admitted to the hospital for any reason from between 2013 and 2018 who were screened for viral markers and determined to be anti-HCV positive. The follow-up performed was then analyzed. RESULTS Viral marker testing was requested for 65,853 patients during the study period. Of those, 64.735 (98.3%) were found to be anti-HCV negative and 1118 (1.7%) were anti-HCV positive. In all, 392 (35.06%) were detected in the gastroenterology department, 417 (37.3%) were patients in the infectious diseases department, and 309 (27.64%) were identified in other clinics, including emergency services, the blood bank, and others. There were 30/392 (7.65%) patients admitted to the gastroenterology clinic who declined a biopsy and/or treatment. In other clinics, 88/309 (28.5%) patients were identified who were not treated for HCV and not followed up because they were not referred to the related specialty department. CONCLUSION It was determined that there was a significant gap in referring patients to the appropriate specialized department following an anti-HCV positive finding and thus to appropriate follow-up and treatment programs.
Collapse
Affiliation(s)
- Mustafa Zanyar Akkuzu
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Orhan Sezgin
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Serkan Yaraş
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Osman Özdoğan
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - İbrahim Yılmaz
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Enver Üçbilek
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Fehmi Ateş
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Engin Altıntaş
- Department of Gastroenterology, Mersin University Faculty of Medicine, Mersin, Turkey
| |
Collapse
|
16
|
Bakhai S, Nallapeta N, El-Atoum M, Arya T, Reynolds JL. Improving hepatitis C screening and diagnosis in patients born between 1945 and 1965 in a safety-net primary care clinic. BMJ Open Qual 2019; 8:e000577. [PMID: 31637319 PMCID: PMC6768492 DOI: 10.1136/bmjoq-2018-000577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 08/06/2019] [Accepted: 09/07/2019] [Indexed: 12/18/2022] Open
Abstract
Individuals born between 1945-1965 represent 81% of all persons chronically infected with hepatitis C virus (HCV) in the USA and are largely unaware of their positive status. The baseline HCV screening rate in this population in an academic internal medicine clinic at a US hospital was less than 3.0%. The goal was to increase the rate of HCV screening in patients born between 1945 and 1965 to 20% within 24 months. The quality improvement team used the Plan Do Study Act Model. Outcome measures included HCV antibody screening, HCV RNA positive rate and linkage to hepatology care. Process measures included HCV antibody order and completion rates. The quality improvement team performed a root cause analysis and identified barriers for HCV screening and linkage to care. The key elements of interventions included redesigning nursing workflow, use of health information technology and educating patients, physicians and nursing staff about HCV. The HCV screening rate was 30.3% (391/1291) within 24 months. The HCV antibody positive rate was 43.5% (170/391), and HCV RNA positive rate was 95.3% (162/170). HCV infection was diagnosed in 12.5% (162/1291) of patients or 41.4% (162/391) of the screened population. Of those positive, 70% (114/162) were linked to hepatology care within the 24-month project timeframe. Eighty percent of patients seen by a hepatologist were treated with direct-acting antivirals agents. The HCV screening rate was sustained at 25.4% during the post-project 1-year period. Engagement of a multidisciplinary team and education to patients, physicians and nursing staff were the key drivers for success.
Collapse
Affiliation(s)
- Smita Bakhai
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Naren Nallapeta
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Mohammad El-Atoum
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Tenzin Arya
- Department of Internal Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| | - Jessica L Reynolds
- Department of Medicine, University at Buffalo – The State University of New York, Buffalo, New York, USA
| |
Collapse
|
17
|
Morales-Arraez D, Alonso-Larruga A, Diaz-Flores F, García Dopico JA, de Vera A, Quintero E, Hernández-Guerra M. Predictive factors for not undergoing RNA testing in patients found to have hepatitis C serology and impact of an automatic alert. J Viral Hepat 2019; 26:1117-1123. [PMID: 31077515 DOI: 10.1111/jvh.13122] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 12/18/2022]
Abstract
The process of diagnosis and linkage to care in cases of hepatitis C virus (HCV) infection remains an obstacle to disease control. The aims of this study were to evaluate predictive factors for not undergoing RNA testing among patients with positive HCV serology and impact of incorporating an automated electronic alert with recommendations in clinical practice. We collected HCV antibody tests requested from October 2011 to September 2014 to evaluate the rate of RNA testing and predictive factors for not undergoing RNA testing. Since October 2014, an automated alert notification has been implemented to remind physicians for testing RNA after a positive HCV test and referral to specialist care. 41 403 HCV antibody tests were requested from 34 073 patients. 870 (2.55%) patients tested positive. After a median of follow-up of 57.0 months (range 45.6-82.1), 37.6% did not have RNA testing. The independent predictors for not undergoing RNA testing were primary care serology requests (P < 0.001), no history of drug use (P = 0.005) and a lack of social support (P = 0.015). The intervention impact was evaluated in a pre-alert cohort (October 2011-September 2014) and a post-alert cohort (October 2014-September 2015). After the incorporation of the alert, the rate of RNA testing increased from 62.4% to 77.7% (P < 0.001). Incomplete assessment of HCV infection is a challenge in primary care. The implementation of an automated alert for recommending RNA testing after a positive HCV antibody test is feasible in clinical practice and increases the rate of patients with RNA testing.
Collapse
Affiliation(s)
- Dalia Morales-Arraez
- Liver Unit, Hospital Universitario de Canarias, Tenerife, Spain.,Instituto Universitario de Tecnologías Biomédicas CIBICAN, Departamento de Medicina Interna, Psiquiatría y Dermatología, Universidad de La Laguna, Tenerife, Spain
| | - Ana Alonso-Larruga
- Central Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Jose A García Dopico
- Central Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Antonia de Vera
- Central Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Enrique Quintero
- Liver Unit, Hospital Universitario de Canarias, Tenerife, Spain.,Instituto Universitario de Tecnologías Biomédicas CIBICAN, Departamento de Medicina Interna, Psiquiatría y Dermatología, Universidad de La Laguna, Tenerife, Spain
| | - Manuel Hernández-Guerra
- Liver Unit, Hospital Universitario de Canarias, Tenerife, Spain.,Instituto Universitario de Tecnologías Biomédicas CIBICAN, Departamento de Medicina Interna, Psiquiatría y Dermatología, Universidad de La Laguna, Tenerife, Spain
| |
Collapse
|
18
|
Jain MK, Rich NE, Ahn C, Turner BJ, Sanders JM, Adamson B, Quirk L, Perryman P, Santini NO, Singal AG. Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre-Post Analysis. Hepatology 2019; 70:40-50. [PMID: 30950085 DOI: 10.1002/hep.30638] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/25/2019] [Indexed: 12/30/2022]
Abstract
Hepatitis C virus (HCV) testing in persons born from 1945 to 1965 has had limited adoption despite guidelines, particularly among racial/ethnic minorities and socioeconomically disadvantaged patients, who have a higher prevalence of disease burden. We examined the effectiveness of a multifaceted intervention to improve HCV screening in a large safety-net health system. We performed a multifaceted intervention that included provider and patient education, an electronic medical record-enabled best practice alert, and increased HCV treatment capacity. We characterized HCV screening completion before and after the intervention. To identify correlates of HCV screening, we performed logistic regression for the preintervention and postintervention groups and used a generalized linear mixed model for patients observed in both preintervention and postintervention time frames. Before the intervention, 10.1% of 48,755 eligible baby boomer patients were screened. After the intervention, 34.6% of the 34,093 eligible baby boomers were screened (P < 0.0001). Prior to the intervention, HCV screening was lower among older baby boomers and providers with large patient panels and higher in high-risk subgroups including those with signs of liver disease (e.g., elevated transaminases, thrombocytopenia), human immunodeficiency virus-positive patients, and homeless patients. Postintervention, we observed increased screening uptake in older baby boomers, providers with larger patient panel size, and patients with more than one prior primary care appointment. Conclusion: Our multifaceted intervention significantly increased HCV screening, particularly among older patients, those engaged in primary care, and providers with large patient panels.
Collapse
Affiliation(s)
- Mamta K Jain
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Chul Ahn
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Barbara J Turner
- Department of Internal Medicine, UT Health Science Center, San Antonio, TX
| | - Joanne M Sanders
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Brian Adamson
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Lisa Quirk
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Patrice Perryman
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Noel O Santini
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.,Parkland Health & Hospital System, Dallas, TX.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| |
Collapse
|