Estimating the scale of chronic hepatitis C virus infection in the EU/EEA: a focus on migrants from anti-HCV endemic countries.

BACKGROUND: Increasing the proportion diagnosed with and on treatment for chronic hepatitis C (CHC) is key to the elimination of hepatitis C in Europe. This study contributes to secondary prevention planning in the European Union/European Economic Area (EU/EEA) by estimating the number of CHC (anti-HCV positive and viraemic) cases among migrants living in the EU/EEA and born in endemic countries, defining the most affected migrant populations, and assessing whether country of birth prevalence is a reliable proxy for migrant prevalence. METHODS: Migrant country of birth and population size extracted from statistical databases and anti-HCV prevalence in countries of birth and in EU/EEA countries derived from a systematic literature search were used to estimate caseload among and most affected migrants. Reliability of country of birth prevalence as a proxy for migrant prevalence was assessed via a systematic literature search. RESULTS: Approximately 11% of the EU/EEA adult population is foreign-born, 79% of whom were born in endemic (anti-HCV prevalence ≥1%) countries. Anti-HCV/CHC prevalence in migrants from endemic countries residing in the EU/EEA is estimated at 2.3%/1.6%, corresponding to ~580,000 CHC infections or 14% of the CHC disease burden in the EU/EEA. The highest number of cases is found among migrants from Romania and Russia (50-60,000 cases each) and migrants from Italy, Morocco, Pakistan, Poland and Ukraine (25-35,000 cases each). Ten studies reporting prevalence in migrants in Europe were identified; in seven of these estimates, prevalence was comparable with the country of birth prevalence and in three estimates it was lower. DISCUSSION: Migrants are disproportionately affected by CHC, account for a considerable number of CHC infections in EU/EEA countries, and are an important population for targeted case finding and treatment. Limited data suggest that country of birth prevalence can be used as a proxy for the prevalence in migrants.

Current prevalence of chronic hepatitis B and C virus infection in the general population, blood donors and pregnant women in the EU/EEA: a systematic review.

This systematic review aimed at estimating chronic hepatitis B (HBV) and C virus (HCV) prevalence in the European Union (EU) and Economic Area (EEA) countries in the general population, blood donors and pregnant women. We searched PubMed©, Embase© and Cochrane Library databases for reports on HBV and HCV prevalence in the general population and pregnant women in EU/EEA countries published between 2005 and 2015. Council of Europe data were used for HBV and HCV blood donor prevalence. HBV general population estimates were available for 13 countries, ranging from 0·1% to 4·4%. HCV general population estimates were available for 13 countries, ranging from 0·1% to 5·9%. Based on general population and blood donor estimates, the overall HBV prevalence in the EU/EEA is estimated to be 0·9% (95% CI 0·7-1·2), corresponding to almost 4·7 million HBsAg-positive cases; and the overall HCV prevalence to be 1·1% (95% CI 0·9-1·4), equalling 5·6 million anti-HCV-positive cases. We found wide variation in HCV and HBV prevalence across EU/EEA countries for which estimates were available, as well as variability between groups often considered a proxy for the general population. Prevalence estimates are essential to inform policymaking and public health practice. Comparing to other regions globally, HBV and HCV prevalence in the EU/EEA is low.

The role of the general practitioner in the screening and clinical management of chronic viral hepatitis in six EU countries.

INTRODUCTION: Chronic viral hepatitis is still a major public health concern in the EU. In order to halt the progression of the disease and to prevent onward transmission, timely recognition and accurate clinical management are crucial. The aim of the present study was to investigate the role of the general practitioner (GP) in the screening of persons at risk and in the clinical management of chronic viral hepatitis patients in six EU countries. METHODS: An online survey among GPs and secondary-care specialists was conducted in the UK, Germany, the Netherlands, Hungary, Italy and Spain. In the GP survey, we used a four-point Likert scale to find out how commonly risk groups are screened. In both surveys, we measured GPs involvement in monitoring clinical indicators in patients undergoing antiviral treatment, and explored whether patients in four clinical scenarios are referred back to primary care. RESULTS: Between five and 10 experts per professional group were surveyed, except for Spain (GPs: n = 2; Specialists: n = 4) and, in the case of the GP survey, Hungary (GPs: n = 1) and Germany (GPs: n = 4). Migrants are variably or not routinely screened for hepatitis B/C in the majority of cases. The majority of GPs reported that hepatitis B/C screening was routinely offered to people who inject drugs. In Hungary, Italy and in the Netherlands, screening sex workers is not a regular practice. As to whether GPs offer screening to men who have sex with men, responses varied; in Germany, the Netherlands and Italy, screening was "variably" or "commonly" implemented, while in Hungary the practice seems to be sporadic. In the UK, screening for hepatitis B seems to be common practice among GPs, while hepatitis C testing is only occasionally offered to this risk group. Most GPs (> 44%) in all countries except Hungary reported that hepatitis B/C screening was very commonly offered to HIV patients. The role of GPs in monitoring hepatitis cases and the referral of cases back to GPs by specialists varied both within and between countries. GPs are unlikely to monitor clinical outcomes other than side effects in patients undergoing treatment. Patients who have had a sustained virological response are usually referred back to GPs, whereas patients undergoing antiviral treatment and those who do not respond to treatment are rarely referred back. CONCLUSIONS: The GP's decision to offer screening to risk groups often seems to be an individual choice of the healthcare professional. Raising GPs' awareness of the disease, for example through the adoption of effective strategies for the dissemination and implementation of the existing guidelines for general practice, is strongly needed. The role of GPs and specialists involved in the management of chronically infected patients should also be clarified, as opinions sometimes differ markedly even within each professional group.

El coste por proceso en cirugía mayor ambulatoria: aplicación a liberación del túnel carpiano / The cost per proceeding in major outpatient surgery: application in carpal tunnel syndrome

Introducción: La gestión por procesos constituye un cambio de paradigma en la forma de gestión de las organizaciones sanitarias. El síndrome del túnel carpiano constituye la causa más frecuente de consulta en cirugía de la mano. El objetivo general del presente trabajo es establecer las bases teóricas del análisis del coste medio por proceso. Como objetivo específico, calcular el coste medio de liberación del síndrome del túnel del carpo (GRD 6) y compararlo con centros de similares características, como indicador de eficiencia. Material y metodología: Análisis de la casuística correspondiente al GRD 6 intervenidos en un año mediante herramientas de gestión clínico-financiera. Se utiliza la metodología de cálculo de coste agregado descendente o top-down. Se calcula el coste medio por proceso a partir del coste total de la Unidad de Responsabilidad, su casuística y los pesos relativos de sus GRD. Resultados: Se presentan las diferencias existentes en el coste medio por proceso del GRD 6 tanto en su versión ambulatoria, con ingreso, entre diferentes servicios de un mismo hospital y entre distintos centros. Conclusión: El sistema de producción hospitalaria, especialmente de la actividad quirúrgica ambulatoria, avanza hacia una gestión por líneas de producto (gestión por procesos). Una verdadera gestión clínica debe gestionar el conocimiento, las personas, la calidad y los recursos financieros. Es necesario que, en los planes de formación de todo profesional médico y, muy especialmente de los médicos en formación, se incluyan temas económicos para que conozcan los recursos que manejan (AU)

Introduction: The management per proceeding makes up a step change in the way the healthcare organizations are managed. Carpal tunnel syndrome is the most frequent cause of consultant in hand surgery. The general objective of this study is to establish the theoretical bases for the analysis of the average cost per proceeding. The specific objective is to calculate the average cost of the Diagnosis-related group (DRG) 6 and to compare it with healthcare centers of similar characteristics, as an indicator of efficiency. Methods: Analysis of the case studies of the DRG 6 that were operated during one year with clinic and financial management tools. The top-down calculation methodology was employed. The average cost per proceeding was calculated on the basis of the total cost of the Responsibility Unit, the cases and the relative importance of the DRG. Results: We present the differences between the average cost per proceeding of the DRG 6, in outpatient and inpatient surgery, between different services of the same hospital and between different healthcare centers. Conclusions: The hospital production system, specially outpatient surgical activity, progresses towards a management per product lining (management per proceeding). A true clinic management must manage knowledge, people, quality and financial resources. It's necessary to include economical issues in the curriculum of every health professional, specially medical doctor under training, in order to allow them understand the resources that they manage (AU)

Cardiac perforation from central venous catheters: survival after cardiac tamponade in an infant.

A 2,210-g infant suffered cardiac tamponade, which resulted from atrial perforation by a central venous catheter. The infant survived due to timely diagnostic and therapeutic intervention. Cardiac tamponade should be suspected in any patient with a central venous catheter whose condition deteriorates suddenly. Immediate chest roentgenogram and echocardiogram may be performed to support the diagnosis; but when the patient's condition is deteriorating, a diagnostic (and therapeutic as well!) pericardiocentesis should be performed without waiting for other diagnostic measures. A review of clinical recognition and diagnostic measures for cardiac perforation and tamponade is presented. Preventive measures to avoid this fatal complication of central venous catheters are suggested, and therapeutic interventions are outlined.

Management of intractable and extensive tracheal stenosis by implantation of cartilage graft.

A variety of methods have been developed to solve the problem of extensive tracheal stenosis. Endoscopic resection with injection of steroids was performed with some success. Resection with end-to-end anastomosis has been attempted in localized tracheal stenosis, but it is not practical in extensive tracheal stenosis. As an alternative to the above procedures, we performed a simpler operation to increase the diameter of the narrow trachea. We treated three children (a 7-month-old, a 2-year-old, and a 3-year-old) who had severe tracheal stenosis. The trachea was explored through a cervical transverse incision. The anterior wall of the trachea at the level of the stenosis was opened longitudinally and the scar in the tracheal lumen was resected. A free-cartilage graft measuring 1 X 4 cm was taken from the third costochondral junction and was wedged and sutured in place into the tracheal opening. This resulted in increasing the internal diameter of the stenotic trachea. A nasotracheal tube was left in place at the end of the procedure for 48 hours. The children are still asymptomatic 19, 10, and 8 months postoperatively. The careful selection and preparation of the patients for this procedure is discussed.

Selective spermatic arteriography for localization of an impalpable undescended testis.

Thirty patients with undescended testes, including 15 children, were studied by selective spermatic angiography. Six patients had both arteriography and venography, and 24 had bilateral arteriography for assessment of testicular size. In 7 patients, arteriography revealed an impalpable testis following unsuccessful surgical exploration. In 17, subsequent surgery confirmed the angiographic findings; testicular agenesis was diagnosed in 7, and catheterization failed in 2. There were no complications. Preoperative testicular arteriography localizes the testis, facilitates surgery, and may aid in tumor detection. Angiographic identification of testicular agenesis precludes exploration. Arteriography is more accurate, simpler, and less complicated than venography.