This thesis investigates the epidemiology of hepatitis B virus infection (HBV) and estimates HBV-related liver disease burden in Vietnam and Australia using a cross-sectional study design and mathematical modelling. A population-based seroprevalence survey was undertaken in rural Northern Vietnam. In a sample of 870 study participants, prevalence of anti-HBV core antibody (anti-HBc) and hepatitis B virus surface antigen (HBsAg) was 68.2% and 19.0%, respectively, and hepatitis B e antigen (HBeAg) was detected in 16.4% of the HBsAg-positive group. Factors associated with HBV infection (anti-HBc and/or HBsAg-positive) were age 60 years or older (adjusted odds ratio (AOR), 3.82; 95% CI, 1.35??10.80; P = 0.01), residence in Vu Thu district (AOR, 3.00; 95% CI, 2.16??4.17; P <0.001), hospital admission (AOR, 2.34; 95% CI, 1.33??4.13; P = 0.003) and history of acupuncture (AOR, 2.01; 95% CI, 1.29??3.13; P = 0.002). Household contact with a person with liver disease (AOR, 2.13; 95% CI, 1.29??3.52; P = 0.003), reuse of syringes (AOR, 1.81; 95% CI, 1.25??2.62; P = 0.002) and sharing of razors (AOR, 1.69; 95% CI, 1.03??2.79; P = 0.04) were independent predictors of HBsAg positivity. Alanine aminotransferase (ALT) level was elevated (>40 IU/L) in 43% of the HBsAg-positive group; the proportion of elevated ALT was higher in HBeAg-positive (65%) compared with HBeAg-negative (39%) (P = 0.02). Based on data from the seroprevalence study, other prevalence estimates and HBV natural history parameters, a mathematical model was used to estimate HBV-related liver disease burden in Vietnam. Estimated chronic HBV prevalence increased from 6.4 million cases in 1990 to around 8.4 million cases in 2005 and was projected to decrease to 8.0 million by 2025. Estimated HBV-related liver cirrhosis and hepatocellular carcinoma (HCC) incidence increased linearly from 21 900 and 9400 in 1990 to 58 650 and 25 000 in 2025. Estimated HBV-related mortality increased from 12 600 in 1990 to 40 000 in 2025. To estimate HBV-related HCC incidence among Australians born in the Asia-Pacific region (APR), a mathematical modelling was developed utilising HBV natural history parameters, HBV prevalence estimates in APR countries and immigration data. Chronic HBV cases among the APR-born population increased rapidly from the late 1970s, reaching a peak of 4182 in 1990. Chronic HBV prevalence increased to more than 53 000 in 2005. Estimates of HBV-related HCC increased linearly from one in 1960 to 140 in 2005, with a projected increase to 250 in 2025. Universal HBV vaccination programs in countries of origin had limited impact on projected HBV-related HCC to 2025. HBV-related HCC survival was analysed in a population-based linkage study in New South Wales (NSW), Australia. Between 1994 and 2002, 278 HCC cases notified to the NSW Cancer Registry were linked to chronic HBV infection notifications to the NSW Health Department. The majority of cases were male (83.5%) and overseas born (93.6%); Asian-born cases accounted for 72.1%. Median survival following HCC diagnosis was 15 months. HCC survival was poorer among older age groups (P <0.001), and among cases with regional spread (HR 3.23; 95% CI, 1.83??5.69; P <0.001) and distant metastases (HR 3.85; 95% CI, 2.44??6.08; P <0.001). Sex, region of birth, and study period (1994??1997 versus 1998??2002) were not associated with HCC survival. The results of these studies show that HBV infection remains a major public health challenge in highly endemic countries such as Vietnam. HBV-related liver disease burden in Vietnam was estimated to increase for at least two decades despite the introduction of a universal infant HBV-vaccination program. Similarly, HBV-related HCC among Australians born in the APR was estimated to continue to increase over the next two decades. Survival for HBV-related HCC even in settings such as Australia continues to be extremely poor. Strategies are required to expand HBV treatment to individuals with chronic HBV infection who are at greatest risk of progression to advanced liver disease.

Caring for an individual with Alzheimer’s disease is especially challenging and impacts every aspect of the lives of the informal caregivers. Informal caregiving is defined as unpaid care provided by family or friends to people with a chronic illness or disability (Young & Newman, 2002). Caregiver burden involves the physical, psychological, social and emotional problems experienced by a caregiver of an impaired loved one (Gwyther & George, 2006). Alzheimer’s disease caregivers report more depression than their caregiving and non-caregiving peers, experience increased physical decline, and often experience financial challenges. Evidence suggests Alzheimer’s disease caregiver burden is a result of both care recipient and caregiver factors. Pearlin et al’s Stress Process model (1990) is widely used to examine triggers in caregiver burden. The model consists of antecedents, stressors, and outcomes. Few studies have examined moderators in the burden process in Alzheimer’s disease caregiving. Whether resilience accounts for variance in outcomes associated with caregiver burden is not addressed in the literature. Data from a convenience sample of Alzheimer’s disease caregivers (N=111) were examined for the purpose of exploring the moderating effect of resilience on the relationship between stressors and caregiver burden predictors. RESULTS: Resilience did not moderate the relationship between the caregiver stressors and caregiver burden. However, results indicated a relationship between resilience and caregiver burden. Specifically, as resilience increases, caregiver burden decreased. This finding highlights the importance of Alzheimer’s caregivers and implementing support and interventions that will increase their resilience.

Introduction: Chronic diseases tend to increase with old age. Older people with chronic disease are commonly suffering from conditions which produce a multiplicity of symptoms and a decreased health-related quality of life. Nurses have a responsibility to prevent, ease or delay a negative outcome through symptom management, or assist in achieving an acceptable level of symptom relief. Aim: The overall aim of the thesis was to describe different aspects of symptom burden from the perspective of community-dwelling people with chronic disease. Methods: This thesis is based upon four papers that used both quantitative and qualitative data to describe different aspects of symptom burden, experienced by people with chronic diseases. Paper (I) is a cross-sectional study with 91 participants diagnosed with chronic obstructive pulmonary disease. Papers (II and IV) are based upon secondary outcome data from a randomized controlled trial with 382 community-dwelling older people with multimorbidity. Paper (II) is a cross-sectional study and Paper (IV) has a descriptive and an explorative design reporting on the trajectory of symptom prevalence and symptom burden. Paper (III) is a qualitative study with participants from the AGe-FIT. Results: Among people diagnosed with COPD the most prevalent symptoms with the highest symptom burden scores were shortness of breath, dry mouth, cough, sleep problems, and lack of energy, with just a few differences between participants with moderate and severe airflow limitation (I). For older people with multimorbidity, pain was the symptom with the highest prevalence and burden. Other highly prevalent symptoms were lack of energy and a dry mouth. Poor vision, likelihood of depression, and diagnoses of the digestive system were independently related to the total symptom burden score (II). The symptoms experienced by the older people were persistent and the symptom burden remained high over time (IV). The experience of living with a high symptom burden was described as an endless struggle. The analysis revealed an overall theme, “To adjust and endure” and three sub-themes, “to feel inadequate and limited”, “to feel dependent”, and “to feel dejected” (III). Conclusions: The results of this thesis indicate the importance of early symptom identification. People with chronic diseases have an unmet need for optimized treatment that focuses on the total symptom burden, and not only disease specific symptoms. A large proportion of older people with multimorbidity suffer a high and persistent symptom burden, and the prevalence and trajectory of pain are high. Older people sometimes think their high age is the reason they experience a diversity of symptoms, and they do not always communicate these to their health-care provider.

Objectives: Evaluate the association of cancer on net worth, consumer debt, mortgage debt, home equity and changes in retirement trends. Methods: Data from the Health and Retirement Study from 1998-2010 was used. Persons had to have a diagnosis of cancer. The index date was the corresponding HRS wave of the year of the first diagnosis of cancer. The pre-index date was 2 years and a 2-year and 4-year post index was observed. Primary outcomes of interest were zero/negative net worth and net worth. Multiple logistic regression was used to test for the association between demographic, economic, human capital, and cancer-related variables on outcomes. Generalized linear models were conducted to assess the association of cancer on net worth, consumer debt, mortgage debt, and home equity. Multinomial logistic regression was performed to assess the association of cancer on retirement. Results: A total of 6,055,110 individuals (weighted) qualified. The majority of patients in this sample were male (53.8%), non-Hispanic (95.5%), and white (90.3%). Marital status (p<0.05), alcohol consumption (p=0.046), hypertension (p = 0.034), private insurance (p=0.001), cancer status (p<0.001), and cancer treatment (p=0.022) were significant predictors of zero/negative net worth 4-years after cancer diagnosis. Patients receiving treatment for their cancer were 71% more likely to have consumer debt 4-years post diagnosis (p=0.006). Patients who reported their cancer improving 4-years post diagnosis were significantly less likely (p=0.008) to have consumer debt (OR=0.59; 95%CI: 0.41-0.87). Cancer treatment and cancer status were significant predictors of mortgage debt (p<0.001 and 0.024, respectively). For individuals whose cancer either improved (OR=1.46; 95%CI: 1.04-2.06) or worsened (OR=4.09; 95%CI: 1.38-12.15), both groups were significantly more likely (p=0.030 and 0.011, respectively) to have home equity 4-years post diagnosis. Cancer status was a significant predictor of individuals transitioning from working to retired (p=0.022).Conclusion: This nationally representative investigation of 6.1 million patients over 50 years of age with cancer found that approximately 65% of cancer patients reported zero/negative net worth of cancer and almost 45% of cancer patients reported consumer debt four-years post diagnosis. Cancer-related characteristics explain a significant amount of the change in net worth four-years post diagnosis of cancer.

The Dublin Regulation determines the Member State responsible for accepting and making a decision on asylum claims lodged in the European Union (‘EU’), Norway and Iceland. It aims to ensure that each asylum claim is examined by one and only one Member State, to put an end to the practice of ‘asylum shopping’ and to prevent repeated applications, both of which have been costly for the receiving Member States and caused severe inefficiencies in the determination processes in the EU in the past. With the first Member State of entry being the major determinant for the allocation of asylum responsibility under the Dublin Regulation, there has been growing discontent among Member States at the external borders of the EU, particularly the southern Member States in the Mediterranean, over what they see as a system that has unjustly placed disproportionate burdens on them regarding the admission of seaborne asylum seekers and the costs associated with it. As a result of changes in migration rules and consequent adjustments in the entry strategy employed by irregular migrants and people smugglers, the Member States at the EU’s ‘southern frontline’ have unwillingly played the role of reluctant hosts to boatloads of unwelcome asylum seekers. This thesis aims to examine how the EU has attempted to tackle the challenging situation of the unauthorised migration of asylum seekers into its territory by sea, and in particular, how it has responded to demands from affected Member States for a more equitable system of asylum responsibility allocation in spite of and outside the Dublin framework. It would argue that the ‘small’ EU Member States in the Mediterranean themselves have, over the last five years at least, become the unexpected drivers of the EU’s declared commitment to the principles of ‘solidarity’, ‘fair sharing of responsibility’ and ‘effective multilateralism’. ‘ Small’ as they may be in terms of resources, size or influence vis-à-vis the larger Member States, the former have been able to create their own mark in a global regime that has traditionally been resistant to the idea of burden-sharing. The measures taken by the EU’s ‘southern frontline’ have collectively changed the landscape of a global protection regime where not only is asylum ‘burden sharing’ highly elusive – its terms and conditions are also dictated by the more powerful sovereign states. While the theoretical point of departure in this study is the influence wielded by the ‘small’ EU Member States in the burden-sharing debate, the degree or level of ‘influence’ small Mediterranean Member States can exercise in pushing for cooperative arrangements is itself determined by a system that is biased towards large states, increasingly securitised, and is therefore limited in both nature and scope. Nevertheless, the experience of ‘burden-sharing’ in the EU between 2005 and 2010 demonstrates that the Member States at the periphery have proactively taken the responsibility for the operationalisation of the founding values and principles of the EU, and through active norm advocacy and related strategies, have been able to achieve what has eluded the global protection regime so far – a refugee burden sharing scheme.

With the threat of avian influenza, influenza laboratory testing and surveillance capacity has increased globally. Data from global surveillance activities have been used to identify circulating influenza strains for vaccine policy decisions, and have provided evidence of influenza disease among various populations. A recent meta-analysis, which includes findings from these surveillance efforts, has shown that influenza contributes to 10% of pediatric respiratory hospitalizations. Although statistical models indicate a high burden of influenza-associated morbidity among older adults and pandemic studies reveal an increase in hospitalizations among young adults, the global burden of seasonal influenza among adults remains unknown. In order to estimate the global burden of seasonal influenza among adult respiratory hospitalizations, we conducted a systematic review of the published literature, and identified 48 eligible articles published between January 1996 and June 2012 that met our inclusion criteria. We combined these published datasets with 29 eligible, unique datasets from year-round, influenza hospital-based surveillance. These combined data covered 50 countries with varying income and vaccine policies. Extracting numbers tested and positive for influenza, we calculated crude median positive proportions and evaluated potential differences in crude proportions among variables using Kruskal-Wallis non-parametric tests. We observed differences by data source and country development status when we included the 2009 pandemic year. With the exclusion of the 2009 pandemic year, we then generated adjusted pooled estimates using the log binomial model. We found 11% of cases from adult respiratory hospitalizations worldwide were laboratory-confirmed for influenza. This pooled estimate was independent of age but increased as country development or income level decreased. Our findings suggest that influenza is an important contributor to severe acute respiratory illness among both young and older adult populations. For countries without reliable influenza data, we provide an estimate that they may use in planning and allocating resources for the control and prevention of influenza.

Bakalauro baigiamajame darbe nagrinėjama administracinės naštos smulkiajam ir vidutiniam verslui, vykdant mokestine prievoles, problema, atsiradimo priežastys, jų mažinimo galimybės. Pirmoje dalyje pateikiami teoriniai samprotavimai apie taip, kas yra administracinė našta, kas ją sukelia, kaip vertinama administracinės naštos problema Lietuvoje ir užsienio šalyse. Tai piltuvėlio principu sisteminta medžiaga: pradedama nuo administracinės naštos bei valstybinio reguliavimo apibrėžimų, tuomet pereinama prie informacinio įpareigojimo sąvokos, ją analizuojant kaip pagrindinę administracinės naštos atsiradimo priežastį ir tik galiausiai prieinama prie administracinės naštos mažinimo vertinimo problematikos. Tolimesnėje darbo eigoje seka Lietuvoje ir užsienio šalyse atliekamų administracinės naštos mažinimo analizė. Praktinėje dalyje vertinamas administracinės naštos smulkiajam ir vidutiniam verslui atsiradimas Kelmės rajone. Pagrindinis naudotas metodas apklausa raštu, kurios metu buvo apklausta 100 smulkaus ir vidutinio verslo atstovų, taip pat buvo atliekamas nestruktūruotas interviu su verslininkais, siekiant gauti papildomos informacijos atvejų analizei. Susisteminus apklausos raštu, interviu ir dokumentų analizės medžiagą pateikiamos išvados ir rekomendacijos. Norint efektyviai mažinti administracinės naštos problemą vykdant mokestines prievoles reikia sistemingai vertinti administracinės naštos sukeliamas laiko ir finansines sąnaudas, verslo subjektai turi patys parodyti... [toliau žr. visą tekstą] / My Bachelor thesis examines the problem of the administrative burden on small and medium businesses due to implementation of the tax obligations. This work also discusses the causes of this problem's occurrence and also the possibilities of their reduction. The first part presents the theoretical reasonings of what the administrative burden is, what factors cause it. This paper also reveals the way of how the problem of the administrative burden is seen in Lithuania and abroad countries. The material is organized according to the funnel principle: starting from the administrative burden and state regulatory definitions, then we come to a concept of the informative obligation which is analysed as a main cause of an administrative burden. The issue of the administrative burden reduction is discussed only at the end of a paper work. The further analysis of the thesis examines the reduction of an administrative burden in Lithuania and the foreign countries. Practical part presents the evaluation of the detailed analysis of the administrative burden on small and medium-sized business in Kelme district. The main method used was a written survey during which 100 representatives of small and medium-sized businesses have been questioned. Unstructured interviews have been also conducted with entrepreneurs in order to obtain an additional information of cases for analysis. Written survey, interviews, and document analysis material have been systemized in order to provide the conclusions... [to full text]

This thesis investigates the epidemiology of hepatitis B virus infection (HBV) and estimates HBV-related liver disease burden in Vietnam and Australia using a cross-sectional study design and mathematical modelling. A population-based seroprevalence survey was undertaken in rural Northern Vietnam. In a sample of 870 study participants, prevalence of anti-HBV core antibody (anti-HBc) and hepatitis B virus surface antigen (HBsAg) was 68.2% and 19.0%, respectively, and hepatitis B e antigen (HBeAg) was detected in 16.4% of the HBsAg-positive group. Factors associated with HBV infection (anti-HBc and/or HBsAg-positive) were age 60 years or older (adjusted odds ratio (AOR), 3.82; 95% CI, 1.35??10.80; P = 0.01), residence in Vu Thu district (AOR, 3.00; 95% CI, 2.16??4.17; P <0.001), hospital admission (AOR, 2.34; 95% CI, 1.33??4.13; P = 0.003) and history of acupuncture (AOR, 2.01; 95% CI, 1.29??3.13; P = 0.002). Household contact with a person with liver disease (AOR, 2.13; 95% CI, 1.29??3.52; P = 0.003), reuse of syringes (AOR, 1.81; 95% CI, 1.25??2.62; P = 0.002) and sharing of razors (AOR, 1.69; 95% CI, 1.03??2.79; P = 0.04) were independent predictors of HBsAg positivity. Alanine aminotransferase (ALT) level was elevated (>40 IU/L) in 43% of the HBsAg-positive group; the proportion of elevated ALT was higher in HBeAg-positive (65%) compared with HBeAg-negative (39%) (P = 0.02). Based on data from the seroprevalence study, other prevalence estimates and HBV natural history parameters, a mathematical model was used to estimate HBV-related liver disease burden in Vietnam. Estimated chronic HBV prevalence increased from 6.4 million cases in 1990 to around 8.4 million cases in 2005 and was projected to decrease to 8.0 million by 2025. Estimated HBV-related liver cirrhosis and hepatocellular carcinoma (HCC) incidence increased linearly from 21 900 and 9400 in 1990 to 58 650 and 25 000 in 2025. Estimated HBV-related mortality increased from 12 600 in 1990 to 40 000 in 2025. To estimate HBV-related HCC incidence among Australians born in the Asia-Pacific region (APR), a mathematical modelling was developed utilising HBV natural history parameters, HBV prevalence estimates in APR countries and immigration data. Chronic HBV cases among the APR-born population increased rapidly from the late 1970s, reaching a peak of 4182 in 1990. Chronic HBV prevalence increased to more than 53 000 in 2005. Estimates of HBV-related HCC increased linearly from one in 1960 to 140 in 2005, with a projected increase to 250 in 2025. Universal HBV vaccination programs in countries of origin had limited impact on projected HBV-related HCC to 2025. HBV-related HCC survival was analysed in a population-based linkage study in New South Wales (NSW), Australia. Between 1994 and 2002, 278 HCC cases notified to the NSW Cancer Registry were linked to chronic HBV infection notifications to the NSW Health Department. The majority of cases were male (83.5%) and overseas born (93.6%); Asian-born cases accounted for 72.1%. Median survival following HCC diagnosis was 15 months. HCC survival was poorer among older age groups (P <0.001), and among cases with regional spread (HR 3.23; 95% CI, 1.83??5.69; P <0.001) and distant metastases (HR 3.85; 95% CI, 2.44??6.08; P <0.001). Sex, region of birth, and study period (1994??1997 versus 1998??2002) were not associated with HCC survival. The results of these studies show that HBV infection remains a major public health challenge in highly endemic countries such as Vietnam. HBV-related liver disease burden in Vietnam was estimated to increase for at least two decades despite the introduction of a universal infant HBV-vaccination program. Similarly, HBV-related HCC among Australians born in the APR was estimated to continue to increase over the next two decades. Survival for HBV-related HCC even in settings such as Australia continues to be extremely poor. Strategies are required to expand HBV treatment to individuals with chronic HBV infection who are at greatest risk of progression to advanced liver disease.

Statement of Problem In the past few years, there has been increased interest in the intravenous administration of antibiotics in the home. The catalyst for this interest has been the need to contain costs and decrease surgical waiting lists in hospitals. However, the scientific evidence for cost containment for home parenteral programs is scant, conflicting and confusing. This study is the first to undertake an economic model based on a cost-benefit framework encompassing both direct and the often-ignored indirect costs. It also examines patient self-administered home parenteral antibiotic therapy (HPAT) within an economic, clinical and humanistic outcomes (ECHO) structure as a source of model inputs. The modelling approach overcomes the analytical and statistical difficulties associated with these early discharge programs due to the small and diverse nature of the populations. Methods and Procedures This study uses data from the Alternate Site Infusion Service (ASIS) at Princess Alexandra Hospital, Brisbane, Australia to populate some fields in the economic model. This service is based on the patient self-administration model and provides early hospital discharge to medically stable patients who require medium to long-term intravenous antibiotics for the treatment of infectious disease. The economic model is described as a probabilistic, second-order, Monte Carlo simulation based on cost-benefit design and constructed from realistic incremental differences in costs and benefits. The multi-dimensional probabilistic sensitivity analysis is used to account for uncertainty present in some of the model inputs. Risk analysis software known as “@Risk” Version 4.5.5 Professional is used to construct the simulation model. The cost and benefit framework, and ultimately inputs, are constructed from primary data emanating from the databases of the ASIS unit, Princess Alexandra Hospital in Brisbane for the period 2001 to 2002, secondary data based on literature reviews, and expert opinion. Societal perspective is chosen to encompass areas such as loss or gain of productivity and carer burden. Clinical outcome is investigated by examining the ASIS database regarding the treatment outcome of HPAT patients. The incidence and mortality rates of nosocomial intravascular bacteraemia (NIB) for hospital and HPAT patients are based on the literature review and included as inputs in the model. Carer burden is determined by the identified carers of ASIS patients with the completion of the mailed Caregiving Distress Scale (CDS) and the Impact of Caring Scale (ICS) instruments. A labour questionnaire was designed to collect data on paid employment, students returning to education and individuals returning to normal daily activities (including forgone leisure activities). The Australian Bureau of Statistics’ (ABS) Australian Standard Classification of Occupations (ASCO) and the ABS gender-specific average weekly wages for nine major work groups are used to estimate productivity of patients and their carers. The value of a hospital bed day was modelled to estimate the value of hospitalisation at the end of a hospital length of stay to avoid using an average bed day cost. The change in the utilisation of nursing, medical and pharmacy human resources due to HPAT is also modelled to avoid using average estimates. A sensitivity analysis is conducted on the value of a hospital bed day to measure the impact on the net benefit. Results The @Risk economic model was undertaken with 10,000 iterations to capture the variability of the net benefit. The value of a hospital bed day appears to have the greatest impact on the net benefit of ASIS with the probability of NIB and incidence of death from NIB in hospital also contributing. The correlation of CDS and the ICS demonstrates a linear relationship, and a total of 93% of carers indicate that they would repeat their participation as a carer. However, most relationships between variables are not statistically significant, or clinically unimportant. Carer burden is suggested to be low in home parenteral antibiotic patients despite the ASIS unit adopting the patient self-administered form of service delivery. However, the number of patients identifying a carer is low and, therefore, there is difficulty in the collection of a suitable sized data set. HPAT failed in 10% of home patients and was fairly comparable with other studies based on the patient self-administered model of service delivery. A total of 58% of HPAT patients (total patients = 123 and 3,939 bed days) returned to work or normal activities with an estimated productivity gain of $190,045 for the economic model of 3,964 bed days. Lost productivity for carers emanating from the survey research was estimated to be $118,121 for the economic model of 3,964 bed days. A mean cost difference of $19,584 between the hospital and home NIB, based on literature probability rates, was estimated indicating a benefit to the HPAT with regard to NIB. Overall, the @Risk model for the ASIS patients representing 3,964 bed days calculated a mean net benefit of $2,450,163 for the HPAT program. A 50% reduction in a hospital bed day value to $253 still resulted in a mean net benefit of $1,447,273 – and a zero net benefit resulted when the value of a hospital bed day reached $112. This suggests that the HPAT program, based on a patient self-administered model of service delivery, represents a viable option for healthcare delivery.

Thesis (doctoral)--Université de Toulouse. Faculté de droit et des sciences ećonomiques, 1980. / At head of title: Universite de Toulouse. Includes bibliographical references.