Management of Rheumatoid Arthritis in Primary Care: A Scoping Review.

Rheumatoid arthritis (RA) can lead to severe joint impairment and chronic disability. Primary care (PC), provided by general practitioners (GPs), is the first level of contact for the population with the healthcare system. The aim of this scoping review was to analyze the approach to RA in the PC setting. PubMed, Scopus, and Web of Science were searched using the MESH terms "rheumatoid arthritis" and "primary care" from 2013 to 2023. The search strategy followed the PRISMA-ScR guidelines. The 61 articles selected were analyzed qualitatively in a table and discussed in two sections, namely criticisms and strategies for the management of RA in PC. The main critical issues in the management of RA in PC are the following: difficulty and delay in diagnosis, in accessing rheumatological care, and in using DMARDs by GPs; ineffective communication between GPs and specialists; poor patient education; lack of cardiovascular prevention; and increase in healthcare costs. To overcome these criticisms, several management strategies have been identified, namely early diagnosis of RA, quick access to rheumatology care, effective communication between GPs and specialists, active patient involvement, screening for risk factors and comorbidities, clinical audit, interdisciplinary patient management, digital health, and cost analysis. PC appears to be the ideal healthcare setting to reduce the morbidity and mortality of chronic disease, including RA, if a widespread change in GPs' approach to the disease and patients is mandatory.

Effects of omega-3 fatty acids on coronary revascularization and cardiovascular events: a meta-analysis.

AIMS: Benefits of pharmacologic omega-3 fatty acid administration in cardiovascular prevention are controversial. Particularly, effects on coronary revascularization are unclear; also debated are specific benefits of eicosapentaenoic acid (EPA). We investigated incident coronary revascularizations, myocardial infarction (MI), stroke, heart failure (HF), unstable angina, and cardiovascular death, in subjects randomized to receive EPA or EPA + docosahexaenoic acid (EPA + DHA) vs. control. METHODS AND RESULTS: Meta-analysis of randomized controlled trials (RCTs) was conducted after MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library search. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed for abstracting data and assessing data quality and validity. Data were pooled using a random effects model. Eighteen RCTs with 134 144 participants (primary and secondary cardiovascular prevention) receiving DHA + EPA (n = 52 498), EPA alone (n = 14 640), or control/placebo (n = 67 006) were included. Follow-up ranged from 4.5 months to 7.4 years. Overall, compared with controls, omega-3 supplementation reduced the risk of revascularization [0.90, 95% confidence interval (CI) 0.84-0.98; P = 0.001; P-heterogeneity = 0.0002; I2 = 68%], MI (0.89, 95% CI 0.81-0.98; P = 0.02; P-heterogeneity = 0.06; I2 = 41%), and cardiovascular death (0.92, 95% CI 0.85-0.99; P = 0.02; P-heterogeneity = 0.13; I2 = 33%). Lower risk was still observed in trials where most participants (≥60%) were on statin therapy. Compared with DHA + EPA, EPA alone showed a further significant risk reduction of revascularizations (0.76, 95% CI 0.65-0.88; P = 0.0002; P-interaction = 0.005) and all outcomes except HF. CONCLUSION: Omega-3 fatty acid supplementation reduced the risk of cardiovascular events and coronary revascularization, regardless of background statin use. Eicosapentaenoic acid alone produced greater benefits. The role of specific omega-3 molecules in primary vs. secondary prevention and the potential benefits of reduced revascularizations on overall health status and cost savings warrant further research.

It is debated whether pharmacologic administration of omega-3 fatty acids reduces cardiac events. In particular, it is unclear whether benefits are actually restricted to the use of eicosapentaenoic acid (EPA), or whether combined administration of EPA + docosahexaenoic acid (DHA) is needed; furthermore, little is known about possible benefits of omega-3 fatty acids in reducing incidence of coronary revascularization procedures. In this meta-analysis of all published evidence of clinical trials comparing EPA alone or EPA + DHA vs. control (134 144 participants), we demonstrate the following: In the overall analysis of all trials, omega-3 supplementation reduced the risk of myocardial infarction and cardiovascular death, to a modest extent. However, when trials administering EPA alone were separately analysed, a further significant risk reduction for cardiovascular outcomes was demonstrated. Importantly, these benefits were also observed in subjects who were already taking statins as part of their chronic therapy.Administration of omega-3 fatty acids, particularly EPA alone, was also associated with a substantial decrease in the risk for subsequent coronary revascularizations. Reduction of revascularization procedures may induce additional benefits on overall health status and associated cost savings.

Prescription and dispensing duration of medicines for hypertension and other chronic conditions: a review of international policies and evidence to inform the Australian setting.

The duration of treatment for which a physician may prescribe a medicine, 'prescription duration', is often dispensed at the pharmacy on multiple occasions of shorter time periods, 'dispensing duration'. These durations vary significantly between and within countries. In Australia, the quantity of medication supplied at each dispensing has recently been extended from 30 to 60 days for a selection of medicines used for chronic health conditions, such as diabetes and hypertension. Dispensing durations vary between countries, with 30, 60 or 90 days being the most common-with 90 days aligning with the recommendation of the 2023 Global Report on Hypertension from the World Health Organization. The full impact of shorter vs longer prescription durations on health costs and outcomes is unknown, but current evidence suggests that 90-day dispensing could reduce costs and improve patient convenience and adherence. More rigorous research is needed.

Assessing Quality of Life, Economic Burden, and Independence Across the Alzheimer's Disease Continuum Using Patient-Caregiver Dyad Surveys.

Background: Alzheimer's disease (AD) and mild cognitive impairment (MCI) have negative quality of life (QoL) and economic impacts on patients and their caregivers and may increase along the disease continuum from MCI to mild, moderate, and severe AD. Objective: To assess how patient and caregiver QoL, indirect and intangible costs are associated with MCI and AD severity. Methods: An on-line survey of physician-identified patient-caregiver dyads living in the United States was conducted from June-October 2022 and included questions to both patients and their caregivers. Dementia Quality of Life Proxy, the Care-related Quality of Life, Work Productivity and Activity Impairment, and Dependence scale were incorporated into the survey. Regression analyses investigated the association between disease severity and QoL and cost outcomes with adjustment for baseline characteristics. Results: One-hundred patient-caregiver dyads were assessed with the survey (MCI, n = 27; mild AD, n = 27; moderate AD, n = 25; severe AD, n = 21). Decreased QoL was found with worsening severity in patients (p < 0.01) and in unpaid (informal) caregivers (n = 79; p = 0.02). Dependence increased with disease severity (p < 0.01). Advanced disease severity was associated with higher costs to employers (p = 0.04), but not with indirect costs to caregivers. Patient and unpaid caregiver intangible costs increased with disease severity (p < 0.01). A significant trend of higher summed costs (indirect costs to caregivers, costs to employers, intangible costs to patients and caregivers) in more severe AD was observed (p < 0.01). Conclusions: Patient QoL and functional independence and unpaid caregiver QoL decrease as AD severity increases. Intangible costs to patients and summed costs increase with disease severity and are highest in severe AD.

Estimating additional health and social costs in eating disorder care for young people during the COVID-19 pandemic: implications for surveillance and system transformation.

BACKGROUND: The impact of the COVID-19 pandemic on young people with eating disorders (EDs) and their families was profound, with surging rates of hospitalizations and referrals reported internationally. This paper provides an account of the additional health and social costs of ED care for young people living in Canada incurred during the COVID-19 pandemic, drawing attention to the available data to inform these estimates while noting gaps in data capacities to account for a full view of the ED system of care. METHODS: Three methodologies were used to capture costs: (1) provincial administrative data holdings available at the Canadian Institute of Health Information (CIHI) were used by Deloitte Access Economics to conduct analyses on costs related to hospitalizations, emergency room visits, outpatient visits with physicians and loss of well-being from being on a waitlist. These were examined across three fiscal years (April 1 to March 31, 2019-2022) to compare costs from one year before to two years after the onset of the pandemic, (2) data collected on support-based community ED organizations and, (3) costs identified by young people, caregivers and health care professionals. RESULTS: Estimates of additional health care costs and social costs arising from ED care waitlists were estimated to have increased by 21% across the two years after the onset of the pandemic and is likely to represent an underestimate of costs. Costs related to some standard ED care services (e.g. day treatment programs) and support-based community ED organizations that saw a 118% increase in services during this time, are some examples of costs not captured in the current cost estimate. CONCLUSIONS: This paper provides a first account of the additional health and social ED care costs associated with the pandemic, which indicate at minimum, a 21% increase. The results invite discussion for more investments in ED services for young people in Canada, as it is unclear if needs are expected to remain elevated. We suggest a call for a national surveillance strategy to improve data holdings to aid in managing services and informing policy. A robust strategy could open the door for much-needed, data-informed, system transformation efforts that can improve ED care for youth, families and clinicians.

The impact of the COVID-19 pandemic on young people with eating disorders and their families was profound, incurring substantial costs to youth, families, health professionals, eating disorder systems of care, and society. This study looks to draw on available data in Canada to estimate the additional health and social costs experienced during the pandemic. Using available national data holdings on eating disorder health system use, survey and discussion groups with individuals who provided or received eating disorder care during the pandemic, and data from support-based community eating disorder organizations, we attempted to capture the fulsomeness of these costs and demonstrate gaps that are likely leading to an incomplete picture. Available data across Canada on hospitalizations, emergency room visits, outpatient visits and loss of wellbeing while on a waitlist were looked at across three fiscal years (April 2019 to March 2022). Overall, an average increase of 21% of additional health care and social costs was seen across the two years after the onset of the pandemic, although this is considered an underestimation. Additional costs such as those for other standard eating disorder treatment options (e.g. day treatment programs) were not captured in these estimates. Additionally, costs related to services received through support-based community eating disorder organizations that saw a 118% increase in services during the pandemic, and private services (e.g. psychologist, dietitian) are some further examples of costs not captured in the current cost estimate. The results of this study highlight that needs and costs related to ED care rose during the pandemic and provides the first account of by how much. Given data limitations, there is a need to revisit national surveillance strategies for eating disorders to help increase accuracy of these estimates and aid in managing services and informing policies related to eating disorder care.

Do we want to know the enormity of women's severe menstrual disorders and chronic pelvic pain?

OBJECTIVE: The purpose of this paper is to call for a nationwide study to assess the prevalence and incidence of women health problems related to menstrual disorders and severe pelvic pain. RATIONALE: The exact prevalence and incidence of endometriosis, adenomyosis, severe painful menstrual disorders, and of severe chronic pelvic pain are unknown. These issues severely impact women's quality of life and represent huge costs for our societies. Using adapted questionnaires, recent progresses in diagnosis and increased fundings announced by politicians, we can and should change this situation by performing a nationwide study to assess prevalence and incidence of these women problems in the French general population. The huge, anticipated costs of this study do appear quite reasonable when accounting for the enormous costs and societal consequences of endometriosis, menstrual disorders and severe pelvic pain. CONCLUSION: These long-awaited data will improve our understanding of the causes, consequences, and natural history of endometriosis. These data will allow women to better understand that pain is not always related to endometriosis, thus preventing unjustified fears. Physicians will be able to adapt and improve medical managements, particularly the diagnosis. Politicians will have the tools to improve women's health and gender equality.

Households catastrophic health expenditure among older people with noncommunicable diseases: A cross-sectional study from Iran.

Background and Aims: Noncommunicable diseases are one of the main difficulties faced by older adults in many countries. The study aimed to investigate the households' catastrophic health expenditure (CHE) among older people with noncommunicable diseases. Methods: This cross-sectional study was conducted between October and December 2022 in Semnan, Iran, with the participation of 400 older individuals suffering from diabetes and hypertension. The Content Validity Ratio (which is calculated based on necessity criterion) and Content Validity Index (which calculated based on relevance, transparency, and simplicity criteria) values of 0.94 and 0.89, respectively, confirmed the content validity of the researcher-made questionnaire. The occurrence of CHE was estimated using the World Health Organization's rule of "allocating at least 40% of non-food household costs to healthcare." Due to the qualitative nature of the data, the χ 2 test was utilized to assess the statistical association between demographic and background variables and occurrence of CHE. Results: Older people with diabetes and hypertension had an annual direct medical costs of $821 averagely, which includes 9.7% for diagnosis, 23.9% for doctor visits, and 66.4% for treatment. Direct medical costs account for around 0.26 of nonfood costs, with 12.5% of seniors facing high medical charges. Age, marital status, type of basic health insurance, diabetes, the time elapsed since initial diabetes diagnosis, the severity of diabetes complications, and the development of diabetes-related visual impairments, are associated with CHE (p < 0.05). Conclusion: While the prevalence of CHE among elderly individuals with diabetes and hypertension is reasonably manageable, targeted promotional efforts are still necessary to protect those at high risk.

Future fire-smoke PM2.5 health burden under climate change in Paraguay.

Recent years have seen a rise in wildfire and extreme weather activity across the globe, which is projected to keep increasing with climate-induced conditions. Air pollution, especially fine particulate matter (PM2.5) concentration, is heavily affected by PM2.5 emissions from wildfire activity. Paraguay has been historically suffering from fires, with an average of 2.3 million hectares burnt per year during the 2003-2021 period. Annual PM2.5 concentration in Paraguay is 13.2 µg/m3, more than double the recommended by the WHO. We estimate that, historically, almost 40 % of fine air particulates can be attributed to fires. Using a random forest algorithm, we estimate future fire activity and fire related PM2.5 under different climate change scenarios. With global warming, we calculate that fire activity could increase by up to 120 % by 2100. Annual fire smoke PM2.5 from fires is expected to increase by 7.7 µg/m3 by 2100. Under these conditions, Paraguay is expected to suffer an increase in 3500 deaths per year attributable to fire smoke PM2.5 by 2100. We estimate the economic cost of fire smoke-related mortality by 2100 at US $ 5600 million, equivalent to 2.6 % of Paraguay's GDP, excluding other health- and productivity-related impacts on society.

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting.

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

Resource utilization and costs related to the management of obstructive hypertrophic cardiomyopathy under the Brazilian supplementary healthcare system´s perspective: results from a modified Delphi panel / Utilização de recursos e custos relacionados ao manejo da cardiomiopatia hipertrófica obstrutiva sob a perspectiva do sistema de saúde suplementar brasileiro: resultados de um painel Delphi modificado

Objective: To generate data on the costs associated with the diagnosis and treatment of obstructive ypertrophic cardiomyopathy (HCM) from the perspective of the private health system in Brazil. Methods: A modified Delphi panel including seven different specialists (three clinical cardiologists with experience in obstructive HCM, two hemodynamicists with experience in septal ablation and two cardiac surgeons with expertise in myectomy), from two Brazilian states (São Paulo and Pernambuco), was conducted between August and November 2022. Two rounds of questions about the use of healthcare resources according to the functional class (NYHA I-IV) and a panel in a virtual platform were conducted to obtain the final consensus. Micro-costing defined costs and unit values were determined based on official price lists. Results: The total diagnosis cost per patient was estimated at BRL 11,486.81. The obstructive HCM management costs analysis showed average annual costs per patient of BRL 17,026.74, BRL 19,401.46, BRL 73,310.07, and BRL 94,885.75 for the functional classes NYHA I, NYHA II, NYHA III, and NYHA IV, respectively. The average costs per patient related to procedures in a year were BRL 12,698.53, BRL 13,462.30, BRL 58,841.67, and BRL 75,595.90 for the functional classes NYHA I, II, III, and IV, respectively. Conclusions: The annual costs of HCM management increased according to the functional class, highlighting the need for safe and effective strategies to improve patient's NYHA functional class while promoting a decrease in the need for invasive therapies.

Objetivo: Gerar dados acerca dos custos associados ao diagnóstico e tratamento da cardiomiopatia hipertrófica (CMH) obstrutiva, sob a perspectiva do sistema de saúde privado no Brasil. Métodos: Um painel Delphi modificado incluindo sete especialistas (três cardiologistas clínicos com experiência em CMH obstrutiva, dois hemodinamicistas com experiência em ablação de septo e dois cirurgiões cardíacos com experiência em miectomia) de dois estados brasileiros (São Paulo e Pernambuco) foi conduzido entre agosto e novembro de 2022. Foram realizadas duas rodadas de perguntas acerca da utilização de recursos de acordo com a classe funcional (NYHA I-IV) e uma reunião virtual para obtenção do consenso final. Os custos foram definidos por meio de microcusteio, e os valores unitários foram definidos com base em listas de preço oficiais. Resultados: O custo total do diagnóstico por paciente foi estimado em R$ 11.486,81. A análise de custos de manejo da CMH obstrutiva mostrou custos médios anuais por paciente de R$ 17.026,74, R$ 19.401,46, R$ 73.310,07 e R$ 94.885,75 para as classes funcionais NYHA I, NYHA II, NYHA III e NYHA IV, respectivamente. Os custos médios por paciente relacionados a procedimentos em um ano foram de R$ 12.698,53, R$ 13.462,30, R$ 58.841,67 e R$ 75.595,90 para as classes NYHA I, II, III e IV, respectivamente. Conclusões: Os custos anuais com o manejo da CMH aumentam de acordo com a classe funcional, destacando a necessidade de estratégias seguras e eficazes capazes de melhorar a classe funcional NYHA do paciente, ao mesmo tempo que promove diminuição da necessidade de terapias invasivas.

Cost-benefit analysis of a multicomponent breastfeeding promotion and support intervention in a developing country.

Background: Studies evaluating breastfeeding promotion and support interventions suggest some economic benefits. This study assessed the direct and indirect costs of a multicomponent breastfeeding promotion and support intervention during the first two years of the infant's life. Methods: This is a cost-benefit analysis of data generated from a randomized controlled trial that aimed at investigating whether provision of a multicomponent breastfeeding promotion and support intervention to Lebanese mothers in the first six months postpartum would improve breastfeeding rates compared to standard obstetric and pediatric care. Data on 339 participants included information on maternal socio-demographics and health, infant nutrition and health, and direct and indirect costs of the intervention. The primary outcome was the benefit-cost ratio (BCR) of the intervention at one, six, 12, and 24 months. Secondary outcomes included the overall costs of infant nutrition and infant-mother dyad health costs during the first two years. Multiple linear regression models investigated the effect of the multicomponent intervention (independent variable) on the overall infant nutrition cost and the overall mother-infant health costs (as dependent variables), adjusting for monthly income and number of children (confounders) at different time points in the first two years. Similar regression models investigated the association between infant nutrition type (exclusive breastfeeding, mixed feeding, artificial milk) and infant nutrition costs and infant-mother health costs. Intention to treat analyses were conducted using SPSS (version 24). Statistical significance was set at a p-value below 0.05. Results: The prevalence of Exclusive/Predominant breastfeeding among participants declined from 51.6% in the first month to 6.6% at the end of second year. The multicomponent breastfeeding intervention incurred 485 USD more in costs than the control group during the first six months but was cost-efficient by the end of the first year (incremental net benefits of 374 USD; BCR=2.44), and by the end of the second year (incremental net benefits of 472 USD; BCR=2.82). In adjusted analyses, the intervention was significantly associated with fewer infant illness visits in the first year (p=0.045). Stratified analyses by the type of infant nutrition revealed that infants who were on Exclusive/Predominant, or Any Breastfeeding had significantly more favorable health outcomes at different time points during the first two years (p<0.05) compared to infants receiving Artificial Milk only, with health benefits being highest in the Exclusive/Predominant breastfeeding group. Moreover, Exclusive/Predominant and Any Breastfeeding had significantly lower costs of infant illness visits, hospitalizations, and infant medications during the two years (p<0.05), but had additional cost for maternal non-routine doctor visits due to breastfeeding (all p values <0.05). Whereas the overall cost (direct and indirect) during the first six months was significantly lower for the Exclusive/Predominant breastfeeding infants (p=0.001), they were similar in infants on Mixed Feeding or Artificial Milk. Conclusions: Breastfeeding is associated with significant economic and infant health benefits in the first two years. In the context of the current economic crisis in Lebanon, this study provides further evidence to policymakers on the need to invest in national breastfeeding promotion and support interventions.

Acidentes por quedas na população idosa: análise de tendência temporal de 2000 a 2020 e o impacto econômico estimado no sistema de saúde brasileiro em 2025 / Fall accidents in older people: a time trend analysis of the period 2000-2020 and the estimated economic burden on the Brazilian health system in 2025

Resumo O acompanhamento longitudinal de indicadores, como os relacionados às quedas acidentais, pode facilitar o planejamento de ações mais eficazes de assistência e prevenção. O objetivo deste artigo é analisar a tendência temporal das variáveis relacionadas aos acidentes de quedas na população idosa no Brasil e no estado de São Paulo entre 2000 e 2020 e estimar o impacto econômico para o SUS em 2025. Este é um estudo observacional retrospectivo com abordagem quantitativa, com dados do Sistema de Informação em Saúde. Foram utilizados os softwares Joinpoint Regression Program versão 4.7.0 e SPSS versão 20.0 para a realização de regressões lineares, além da análise Average Annual Percent Change (AAPC), adotando um intervalo de confiança de 95%. No país, houve aumento das internações nos dois períodos analisados, assim como os gastos totais, em todos os segmentos analisados. Em concordância no estado de São Paulo, o valor total e as internações apresentaram aumento (AAPC, sendo 8,5% e 4,3% respectivamente). No ano de 2025, as internações por quedas no Brasil estarão próximas a 150 mil, gerando custos em torno de R$ 260 milhões. Houve o aumento das variáveis analisadas, mostrando a importância de programas de prevenção de quedas associados a políticas públicas nacionais.

Abstract Longitudinal monitoring of indicators of accidental falls can facilitate the planning of effective care and prevention actions. This article aims to analyze temporal trends in variables related to falls among older persons in Brazil and in the state of São Paulo during the period 2000-2020 and estimate the projected economic burden on the health system in 2025. We conducted a quantitative retrospective observational study using data from the Health Information System. The Joinpoint Regression Program version 4.7.0 and SPSS version 20.0 were used to perform linear regression and calculate the Average Annual Percent Change (AAPC), adopting a 95% confidence interval. There was an increase in mean and total admissions costs due to falls at national level in both intervals of the study period. There was an increase in total admissions costs and the total number of admissions due to falls in the state of São Paulo (AAPC of 8.5% and 4.3%, respectively). Projections for the year 2025 suggest that the total number of admissions due to falls in Brazil will be around 150,000, resulting in costs of approximately R$ 260 million. There was an increase in the variables analyzed by this study, revealing the importance of fall prevention programs associated with national public policies.

The Gluten-Free Diet for Celiac Disease: Critical Insights to Better Understand Clinical Outcomes.

The gluten-free diet (GFD) remains a complex paradigm in managing celiac disease (CeD) in children and adults, and there are many reasons why GFD adherence should be strict to improve outcomes. However, this is a challenging task for patients, since they need to have access to quality healthcare resources that facilitate optimal GFD adherence. Understanding the strengths and weaknesses of the GFD, tackling coexisting nutritional deficiencies, and dealing with complex situations, such as seronegative CeD or non-responsive CeD, all require the involvement of a multidisciplinary team. The short- and long-term follow-up of CeD patients should preferably be performed by a combined Gastroenterology and Nutrition service with well-defined quality standards and the multidisciplinary involvement of physicians, nurses, dietitians, and psychologists. Nutritional advice and counseling by an experienced dietitian can reduce the costs associated with long-term follow-up of CeD patients. Likewise, psychological interventions may be essential in specific scenarios where implementing and sustaining a lifelong GFD can cause a significant psychological burden for patients. This manuscript aims to provide guidelines to improve clinical practice in the follow-up and monitoring of CeD patients and provide information on the nutritional risks of an ill-advised GFD. Clinicians, biochemists, food technologists, dietitians, and psychologists with a global view of the disease have been involved in its writing.

The True Price of External Health Effects from Food Consumption.

Although global food consumption costs more in terms of impact on human life than money is spent on it, health costs have not been consistently quantified or included in food prices to date. In this paper, a method to determine the external health costs of nutrition and dietetics is developed by employing the cost-of-illness (COI) and true cost accounting (TCA) approaches. This is done exemplarily for the reference country Germany. The results show that 601.50 € per capita and 50.38 billion € in total external health costs are incurred annually due to nutrition. Overall, most costs are accrued through excessive meat consumption (32.56% of costs), deficient whole grain intake (15.42% of costs), and insufficient uptake of legumes (10.19% of costs). Comparing the external health costs with the external environmental costs in Germany, it can be seen that of the total annual costs of around 153.86 billion €, 67.26% originate from environmental impacts and 32.74% from impacts on human life. In order to achieve the 17 Sustainable Development Goals and to increase family as well as public health, there is a need to internalise these external costs into actual food prices.

Confinamiento involuntario durante la Pandemia COVID -19: Costos en la salud mental y psicosocial / Involuntary confinement during the COVID -19 Pandemic: Mental and psychosocial health costs

Resumen Objetivo: Identificar costos del confinamiento involuntario por la pandemia COVID -19 en la salud mental y psicosocial. Materiales y Métodos: Se realiza una revisión exploratoria documental del confinamiento involuntario y las afecciones o costes en el ser humano, se realizó una búsqueda en bases de datos bibliográficos y a través de internet en revistas y organismos públicos de cuatro descriptores y sus combinaciones, salud mental, salud psicosocial, costos en la pandemia COVID -19, confinamiento involuntario, entre los años 2019 a 2021. Luego de la localización de 20 estudios se realizó una selección y análisis de la documentación, excluyendo 5 de ellos que no eran relevantes para el objetivo, para el análisis de datos se estructuró la información, en costos en la salud mental identificando afectaciones neurofisiológicas como la confusión en el sistema lucha-huida y la hiperactivación y/o hipoactivación del sistema nervioso y en costos psicosociales ante el confinamiento como la sensación de amenaza anticipada y continua, ansiedad, miedo, tristeza, dolor, depresión, sobre estrés, traumas, vulnerabilidad y cambios culturales. Resultados: La pandemia COVID-19 es inédita, histórica, multinacional y de impacto multidimensional, la falta de mitigación de esta y el tiempo excedido de resistirla ha expuesto al ser humano a continuos estresores que erosionan la seguridad y causan incertidumbre, aunado a ello, durante la pandemia el confinamiento ha traído consigo altos costos en la salud mental de tipo neurológicos y psicosociales tales como el sobre-estrés, síntomas ansioso-depresivos, vulnerabilidad en la integridad personal y social. Conclusiones: Se requiere generar estrategias de bienestar emocional para disminuir el impacto en la salud mental, psíquica y al entramado social a partir de propiciar la recuperación de redes de empatía, benevolencia, compasión, apoyo solidario, colectivizando el dolor y las perdidas, diluyendo el impacto de esta al recuperar la confianza y seguridad en uno mismo, en los otros.

Abstract Objective: To identify the costs of involuntary confinement due to the COVID-19 pandemic in the mental and psychosocial health. Materials and methods: An exploratory documentary review of involuntary confinement and its costs in the human nature was carried out. Four descriptors and their combinations, mental health, health psychosocial, costs in the COVID -19 pandemic, and involuntary confinement were searched in bibliographic databases and online in journals and public organizations from 2019 to 2021. 20 studies were found. After selecting and analyzing the documentation five studies were excluded as they were not relevant. To analyze the data, the information was classified in mental health costs, identifying neurophysiological effects such as confusion in the fight-flight system and hyperactivation and/or hypoactivation of the nervous system, and in psychosocial costs in the face of confinement, such as the feeling of anticipated and continuous threat, anxiety, fear, sadness, pain, depression, over stress, trauma, vulnerability, and cultural changes. Results: The COVID-19 pandemic is unprecedented, historical, multinational and has a multidimensional impact. The lack of mitigation and the time exceeded resisting it has exposed the humans to continuous stressors that undermine confidence and cause uncertainty. In addition, during the pandemic, confinement brought with it high mental health costs of a neurological and psychosocial nature, such as overstress, anxious-depressive symptoms, vulnerability in personal and social integrity. Conclusions: It is necessary to generate emotional well-being strategies to reduce the impact on mental and psychic health and the social fabric by promoting the recovery of networks of empathy, benevolence, compassion, solidarity support, collectivizing pain and losses, thus recovering confidence and security in oneself and in others.

Parents of children with disability: Mental health outcomes and utilization of mental health services.

BACKGROUND: Caring for a child with disability may result in stress and difficulties for parents, leading to mental health problems. OBJECTIVE: This study aims to investigate the prevalence of mental health problems, mental health service utilization, and costs in parents of children with disabilities compared to parents of children without disabilities. METHODS: We used data from the Longitudinal Study of Australian Children, a nationally representative sample of children recruited in 2004 with biennial follow-up and linkage to out-of-hospital health service use and billing data for the parents. Descriptive analyses were used to present parental mental health measured using the Kessler 6. Generalized linear models were conducted to examine whether being the parent of a child with disability was associated with higher mental health service utilization and costs compared to those without disability. RESULTS: A total of 4935 children and their parents were included in this study. There was a higher prevalence of mental health problems for parents of children with disabilities compared to those without in all child ages. Regression analyses indicated that parents of children aged 12-17 years with disabilities had significantly higher mental health service utilization and costs compared to parents of children without disabilities (biennial cost difference = $86.37, 95%CI ($15.67-$157.07)). However, these differences were not observed among parents of children aged 4-11 years. CONCLUSION: There are high levels of mental health concerns among parents of children with disabilities in Australia. Mental health interventions are needed to support parents of children aged 4-11 years where there appear to be unmet health needs.

Health Treatment Cost of Holsteins in Eight High-Performance Herds.

Health treatments of Holstein cows (n = 2214) were recorded by the owners of eight high-performance dairy herds in Minnesota. Cows calved from March 2008 to October 2015, and 14 types of health treatments were uniformly defined across the herds. Specific types of health treatment were subsequently assigned a cost based on the mean veterinary cost obtained from the veterinary clinics that serviced the eight herds. A fixed labor cost for time (USD 18/h) associated with specific types of health treatment was determined based on interviews with the herd owners and was added to the veterinary cost. Health treatment cost was then partitioned into five health categories: mastitis (including mastitis diagnostic test), reproduction (cystic ovary, retained placenta, and metritis), lameness (hoof treatments), metabolic (milk fever, displaced abomasum, ketosis, and digestive), and miscellaneous (respiratory, injury, and other). Lactations of cows were divided into six intervals that corresponded with stage of lactation based on days in milk. The first interval of lactation was 30 days in length, followed by four intervals of 60 days each, and the final interval started on day 271 and had variable length because it continued to the end of lactation and included the dry period. Health treatment cost was summed within each interval of lactation and subsequently across lactations by parity. Statistical analysis by parity included the fixed effects of herd, interval, and the interaction of herd and interval, with interval regarded as a repeated measure of cows. Health treatment cost was highest during the first interval for all five parities of cows and ranged from USD 22.87 for first parity to USD 38.50 for fifth parity. Reproduction treatment cost was about one-half of the total health treatment cost during the first interval in all five parities. Metabolic treatment cost during the first interval ranged from USD 3.92 (in first parity) to USD 12.34 (in third parity). Compared to the other health categories, mastitis treatment cost was most evenly distributed across intervals of lactation in all parities. Lameness treatment cost was highest during mid- or late-lactation across parities and reflected the time when cows received routine hoof trimming. Additionally, treatment cost across health categories was summed across intervals of lactation for each cow, and the total health cost of cows varied substantially from herd to herd and ranged from USD 23.38 to USD 74.60 for first parity and usually increased with parity.

Health and economic outcomes of a universal early intervention for parents and children from birth to age five: evaluation of the Salut Programme using a natural experiment.

BACKGROUND: The aim of this study was to investigate the health and economic outcomes of a universal early intervention for parents and children, the Salut Programme, from birth to when the child completed five years of age. METHODS: This study adopted a retrospective observational design using routinely collected linked register data with respect to both exposures and outcomes from Västerbotten county, in northern Sweden. Making use of a natural experiment, areas that received care-as-usual (non-Salut area) were compared to areas where the Programme was implemented after 2006 (Salut area) in terms of: (i) health outcomes, healthcare resource use and costs around pregnancy, delivery and birth, and (ii) healthcare resource use and related costs, as well as costs of care of sick child. We estimated total cumulative costs related to inpatient and specialised outpatient care for mothers and children, and financial benefits paid to mothers to stay home from work to care for a sick child. Two analyses were conducted: a matched difference-in difference analysis using the total sample and an analysis including a longitudinal subsample. RESULTS: The longitudinal analysis on mothers who gave birth in both pre- and post-measure periods showed that mothers exposed to the Programme had on average 6% (95% CI 3-9%) more full-term pregnancies and 2% (95% CI 0.03-3%) more babies with a birth weight ≥ 2500 g, compared to mothers who had care-as-usual. Savings were incurred in terms of outpatient care costs for children of mothers in the Salut area ($826). The difference-in-difference analysis using the total sample did not result in any significant differences in health outcomes or cumulative resource use over time. CONCLUSIONS: The Salut Programme achieved health gains, as a health promotion early intervention for children and parents, in terms of more full-term pregnancies and more babies with a birth weight ≥ 2500 g, at reasonable cost, and may lead to lower usage of outpatient care. Other indicators point towards positive effects, but the small sample size may have led to underestimation of true differences.

Time optimization in primary care - chronic prescription cost.

INTRODUCTION: Time optimization is a common goal to most health information institutions. In several countries, chronic electronic renewal prescriptions were one of the main focuses when implementing information systems. In Portugal, Electronic Medical Prescription (PEM®) software is used for most electronic prescriptions. This study aims to quantify the time spent in chronic prescription renewal appointments (CPRA) in primary care and its impact in the Portuguese National Health System (SNS). METHODS: Eight general practitioners (GP) were included in the study during February 2022. The average duration of 100 CPRA was obtained. To determine the number of CPRA performed every year, a primary care BI-CSP® platform was used. Using Standard Cost Model and average medical doctor hourly rate in Portugal we estimated CPRA global costs. RESULTS: Each doctor spent on average 1:55 ± 01:07 min per CPRA. There were 8295 GP working in 2022. A total 635 561 CPRA were performed in 2020 and 774 346 in 2021. In 2020, CPRA costs ranged 303 088 ± 179 419€, and in 2021 that number increased to 369 272 ± 218 599€. CONCLUSION: This is the first study to quantify CPRA's real cost in Portugal. A PEM® software update would allow daily savings, ranging from 830€ (± 491€) in 2020 and 1011€ (± 598€) in 2021. That change could allow hiring 8 ± 5 GP in 2020 and 12 ± 7 in 2021.

Burden of lung cancer and predicted costs of occupational exposure to hexavalent chromium in the EU - The impact of different occupational exposure limits.

BACKGROUND: Exposure to hexavalent chromium [Cr(VI)] occurs widely in occupational settings across the EU and is associated with lung cancer. In 2025, the occupational exposure limit is set to change to 5 µg/m3. Current exposure limits are higher, with 10 µg/m3 as a general limit and 25 µg/m3 for the welding industry. We aimed to assess the current burden of lung cancer caused by occupational exposure to Cr(VI) and to evaluate the impact of the recently established EU regulation by analysing different occupational exposure limits. METHODS: Data were extracted from the literature, the Global Burden of Disease 2019) study, and Eurostat. We estimated the cases of cancer attributable to workplace exposure to Cr(VI) by combining exposure-effect relationships with exposure data, and calculated related DALYs and health costs in scenarios with different occupational exposure limits. RESULTS: With current EU regulations, 253 cases (95%UI 250.96-255.71) of lung cancer were estimated to be caused by Cr(VI) in 2019, resulting in 4684 DALYs (95%UI 4683.57-4704.08). In case the welding industry adopted 10 µg/m3, a decrease of 43 cases and 797 DALYs from current values is expected. The predicted application of a 5 µg/m3 limit would cause a decrease of 148 cases and 2746 DALYs. Current costs are estimated to amount to 12.47 million euros/year (95%UI 10.19-453.82), corresponding to 39.97 million euros (95%UI 22.75-70.10) when considering costs per DALY. The limits implemented in 2025 would lead to a decrease of 23.35 million euros when considering DALYs, with benefits of introducing a limit value occurring after many decades. Adopting a 1 µg/m3 limit would lower costs to 1.04 million euros (95%UI 0.85-37.67) and to 3.33 million euros for DALYs (95%UI 1.89-5.84). DISCUSSION: Assessing different scenarios with different Cr(VI) occupational exposure limits allowed to understand the impact of EU regulatory actions. These findings make a strong case for adapting even stricter exposure limits to protect workers' health and avoid associated costs.