GLOBAL ENDOCRINOLOGY: Global perspectives in endocrinology: coverage of iodized salt programs and iodine status in 2020.

Iodine deficiency has multiple adverse effects on growth and development. Diets in many countries cannot provide adequate iodine without iodine fortification of salt. In 2020, 124 countries have legislation for mandatory salt iodization and 21 have legislation allowing voluntary iodization. As a result, 88% of the global population uses iodized salt. For population surveys, the urinary iodine concentration (UIC) should be measured and expressed as the median, in µg/L. The quality of available survey data is high: UIC surveys have been done in 152 out of 194 countries in the past 15 years; in 132 countries, the studies were nationally representative. The number of countries with adequate iodine intake has nearly doubled from 67 in 2003 to 118 in 2020. However, 21 countries remain deficient, while 13 countries have excessive intakes, either due to excess groundwater iodine, or over-iodized salt. Iodine programs are reaching the poorest of the poor: of the 15 poorest countries in the world, 10 are iodine sufficient and only 3 (Burundi, Mozambique and Madagascar) remain mild-to-moderately deficient. Nigeria and India have unstable food systems and millions of malnourished children, but both are iodine-sufficient and population coverage with iodized salt is a remarkable 93% in both. Once entrenched, iodine programs are often surprisingly durable even during national crises, for example, war-torn Afghanistan and Yemen are iodine-sufficient. However, the equity of iodized salt programs within countries remains an important issue. In summary, continued support of iodine programs is needed to sustain these remarkable global achievements, and to reach the remaining iodine-deficient countries.

Vision for menopause care in the UK.

Menopause is a major life event affecting all women in a variety of ways, both short and long term. All women should have access to accurate information, available in all forms and through all recognised sources. All healthcare professionals should have a basic understanding of the menopause and know where to signpost women for advice, support and treatment whenever appropriate. Every primary care team should have at least one nominated healthcare professional with a special interest and knowledge in menopause. All healthcare professionals with a special interest in menopause should have access to British Menopause Society Menopause Specialists for advice, support, onward referral and leadership of multidisciplinary education. With the introduction of the comprehensive British Menopause Society Principles and Practice of Menopause Care programme, the society is recognised throughout the UK as the leading provider of certificated menopause and post reproductive health education and training for healthcare professionals. Restrictions imposed by the coronavirus pandemic have been a springboard for the British Menopause Society to bring innovations to the services provided for our membership and for healthcare professionals throughout the UK.

Outreach marketing may be a successful strategy for NHS libraries.

This dissertation study investigates the ways that NHS libraries are currently marketing their services within their organisation and was submitted as part of the MA Library and Information Management at the University of Sheffield in 2019. This paper presents the findings from twelve semi-structured interviews carried out with NHS library managers in the East of England to identify the most and least successful methods, and in comparison with that which is currently in the general marketing literature. The study found that outreach marketing was the most effective and that librarians are currently conducting marketing to the best of their ability, but they lack time and funding to be able to make the most of their promotional campaigns. F.J.

How does it affect service delivery under the National Health Insurance Scheme in Ghana? Health providers and insurance managers perspective on submission and reimbursement of claims.

INTRODUCTION: In 2003, the Government of Ghana launched the National Health Insurance Scheme (NHIS) to enable all Ghanaian residents to have access to health services at the point of care without financial difficulty. However, the system has faced a number of challenges relating to delays in submission and reimbursement of claims. This study assessed views of stakeholders on claims submission, processing and re-imbursement under the NHIS and how that affected health service delivery in Ghana. METHODS: The study employed qualitative methods where in-depth interviews were conducted with stakeholders in three administrative regions in Ghana. Purposive sampling method was used to select health facilities and study participants for the interviews. QSR Nvivo 12 software was used to code the data into themes for thematic analysis. RESULTS: The results point to key barriers such as lack of qualified staff to process claims, unclear vetting procedure and the failure of National Health Insurance Scheme officers to draw the attention of health facility staff to resolve discrepancies on time. Participants perceived that lack of clarity, inaccurate data and the use of non-professional staff for NHIS claims vetting prolonged reimbursement of claims. This affected operations of credentialed health facilities including the provision of health services. It is perceived that unavailability of funds led to re-use of disposable medical supplies in health service delivery in credentialed health facilities. Stakeholders suggested that submission of genuine claims by health providers and regular monitoring of health facilities reduces errors on claims reports and delays in reimbursement of claims. CONCLUSION: Long delays in claims reimbursement, perceived vetting discrepancies affect health service delivery. Thus, effective collaboration of all stakeholders is necessary in order to develop a long-term strategy to address the issue under the NHIS to improve health service delivery.

Metformin use and risk of COVID-19 among patients with type II diabetes mellitus: an NHIS-COVID-19 database cohort study.

AIMS: The relationship between metformin therapy and the risk of coronavirus disease (COVID-19) has not been reported among patients with type 2 diabetes mellitus (DM). We aimed to investigate whether metformin therapy was associated with the incidence of COVID-19 among type 2 DM patients in South Korea. METHODS: The National Health Insurance Service-COVID-19 cohort database, comprising COVID-19 patients from 1 January 2020 to 4 June 2020, was used for this study. Among them, adult patients with type 2 DM were included in this study. Metformin users were defined as those who had been prescribed continuous oral metformin for over a period of ≥ 90 days, and the control group was defined as all other patients. RESULTS: Overall, 27,493 patients with type 2 DM (7204, metformin user group; 20,289, control group) were included. After propensity score matching, 11,892 patients (5946 patients in each group) were included in the final analysis. In the logistic regression analysis, the odds of metformin users developing COVID-19 was 30% lower than that of the control group [odds ratio (OR): 0.70, 95% confidence interval (CI): 0.61-0.80; P < 0.001]. However, in the multivariate model, metformin use was not associated with hospital mortality when compared with that of the control group (OR: 1.26, 95% CI: 0.81-1.95; P = 0.301). CONCLUSIONS: Metformin therapy might have potential benefits for the prevention of COVID-19 among patients with type 2 DM in South Korea. However, it did not affect the hospital mortality of type 2 DM patients diagnosed with COVID-19.

A cross-sectional study investigating the relationship between handgrip strength with multimorbidity in Korean adults: Findings from the Korea National Health and Nutrition Examination Survey VI-VII (2014-2017).

ABSTRACT: To date research investigating the associations between handgrip strength and multimorbidity when stratifying by age and sex is limited. Furthermore, this is the first study in a Korean population, and the first to include adults ≥ 19 years of age. Here we investigated the associations between handgrip strength and multimorbidity in Korean adults aged ≥ 19 years.In this cross-sectional study data from the Korean National Health and Nutrition Examination Survey were used. Multimorbidity was defined as having 2 or more chronic diseases. A total of 19,779 participants were eligible for the study (8730 male and 11,049 female). We grouped and analysed participants based on age and sex (men and women aged 19-49 years, men and women aged 50-80 years) and examined the associations between handgrip strength and multimorbidity using multivariate logistic regressions using stratification by age, sex and body mass index (BMI).Multivariate logistic regressions revealed a significant inverse association irrespective of sex, between relative handgrip strength and multimorbidity. Participants with the lowest handgrip strength had a significantly higher odds ratio (OR) of multimorbidity (men aged 19-49 years: 3.76 and aged 50 years to 80 years: 2.11; women aged 19 years to 49 years: 1.52 and aged 50-80 years: 2.15) when compared to those with highest handgrip strength after adjusting for confounding variables. The highest OR was observed in men aged 19 years to 49 years with a BMI ≥ 25 kg/m2.In the current study we observed a significant inverse relationship between handgrip strength and multimorbidity in males and females with 2 or more chronic diseases. Male participants with a low handgrip strength aged between 19 years to 49 years with a BMI ≥25 kg/m2 may be at greater risk of multimorbidity. This study highlights the need for further longitudinal studies to investigate the effects of increasing handgrip strength combined with weight loss, as an effective strategy to reduce the incidence of multimorbidity.

Treatment gaps and challenges in epilepsy care in the Philippines.

OBJECTIVE: Epilepsy is a neurologic disease that carries a high disease burden and likely, a huge treatment gap especially in low-to-middle income countries (LMIC) such as the Philippines. This review aimed to examine the treatment gaps and challenges that burden Philippine epilepsy care. MATERIALS & METHODS: Pertinent data on epidemiology, research, health financing and health systems, pharmacologic and surgical treatment options, cost of care, and workforce were obtained through a literature search and review of relevant Philippine government websites. RESULTS: The estimated prevalence of epilepsy in the Philippines is 0.9%. Epilepsy research in the Philippines is low in quantity compared with the rest of Southeast Asia (SEA). Inequities in quality and quantity of healthcare services delivered to local government units (LGUs) have arisen because of devolution. Programs for epilepsy care by both government and nongovernment institutions have been implemented. Healthcare expenditure in the Philippines is still largely out-of-pocket, with only partial coverage from the public sector. There is limited access to antiseizure medications (ASMs), mainly due to cost. Epilepsy surgery is an underutilized treatment option. There are only 20 epileptologists in the Philippines, with one epileptologist for every 45,000 patients with epilepsy. In addition, epilepsy care service delivery has been further impeded by the coronavirus disease of 2019 (COVID-19) pandemic. CONCLUSION: There is a large treatment gap in epilepsy care in the Philippines in terms of high epilepsy disease burden, socioeconomic limitations and inadequate public support, sparse clinico-epidemiologic research on epilepsy, inaccessibility of health care services and essential pharmacotherapy, underutilization of surgical options, and lack of specialists capable of rendering epilepsy care. Acknowledgment of the existence of these treatment gaps and addressing such are expected to improve the overall survival and quality of life of patients with epilepsy in the Philippines.

1º Relatório de monitoramento e avaliação da estratégia de saúde digital para o Brasil: 2020-2028 [recurso eletrônico] / 1º Brazilian national digital health strategy: 2020-2028 [eletronic resource]

Este documento, apreciado e aprovado na 38ª Reunião Ordinária do CGESD, em 6 de novembro de 2020, apresenta o primeiro relatório de monitoramento e avaliação da Estratégia de Saúde Digital para o Brasil 2020-2028 (ESD28) (BRASIL, 2020a). O relatório tem o objetivo de identificar e propor os recursos organizacionais e operacionais para que este instrumento-chave de Monitoramento e Avaliação de Saúde Digital tenha periodicidade semestral e cumpra os propósitos definidos na ESD28

This document, appraised and approved in the 38th Ordinary Meeting of CGESD, on November 6th, 2020, introduces the first Brazilian National Digital Health Strategy 2020-2028 monitoring and evaluation report (ESD28) (BRASIL, 2020a). The report aims to and propose the organizational and operational resources so this key Digital Health monitoring and evaluation instrument has biannual periodicity and meets the purposes defined in the ESD28

Experiências de formação no contexto da Política Nacional de Educação Popular em Saúde no Sistema Único de Saúde / Experiencias de formación en el contexto de la Política Nacional de Educación Popular en Salud en el Sistema Brasileño de Salud / Education experiences in the context of the National Policy for Popular Education in Health in the Brazilian National Health System

Este artigo apresenta processos formativos que constituíram estratégias para a implementação da Política Nacional de Educação Popular em Saúde (PNEPS) no Sistema Único de Saúde (SUS) e foram desenvolvidos com a perspectiva pedagógica da Educação Popular (EP), conforme fundamentada por Paulo Freire. São eles: o Curso de Educação Popular em Saúde para Agentes Comunitários e de Vigilância em Saúde (EdPopSUS), o Projeto de Pesquisa e Extensão "Vivências de Extensão em Educação Popular e Saúde no SUS" (Vepop-SUS) e o Curso de Formação Histórica e Política para Estudantes das Áreas da Saúde (FHP). Apontaram-se contextualizações e detalhamentos metodológicos dessas experiências, bem como aproximações, complementariedades e distanciamentos entre elas. Por meio das dimensões e dos enfoques explicitados, indica-se que a EP configura um caminho teórico e metodológico potente para a formação em saúde na perspectiva do bem viver e da emancipação humana. (AU)

Este artículo presenta procesos formativos que constituyeron estrategias para la implementación de la Política Nacional de Educación Popular en Salud en el Sistema Brasileño de Salud (SUS) y que se desarrollaron desde la perspectiva pedagógica de la Educación Popular (EP), conforme fundamentación de Paulo Freire. Son ellos: el Curso de Educación Popular en Salud para Agentes Comunitarios y de Vigilancia en Salud (EDPOPSUS), el Proyecto de Investigación y Extensión "Vivencias de Extensión en Educación Popular y Salud en el SUS" (VEPOP-SUS) y el Curso de Formación Histórica y Política para Estudiantes de las Áreas de la Salud (FHP). Se señalaron puestas en contexto y detallados metodológicos de esas experiencias, así como aproximaciones, complementariedades y distanciamientos entre ellas. Por medio de las dimensiones y enfoques explicitados, se indica que la EP configura un camino teórico y metodológico potente para la formación en salud desde la perspectiva del bien vivir y de la emancipación humana. (AU)

This article presents the educational processes that constituted strategies for the implementation of the National Policy for Popular Education in Health in the Brazilian National Health System (SUS) and were developed with the pedagogical perspective of Popular Education (PE), as substantiated by Paulo Freire. These are namely: the Popular Education Course on Health for Community and Health Surveillance Agents (EDPOPSUS), the Research and Extension Project "Extension Experiences in Popular Education and Health in SUS" (VEPOP-SUS) and the Historical and Political Education Course for Students of the Health Care Area (FHP). Contextualization and methodological details of these experiences were pointed out, as well as approximations, complementarities and differences between them. Through explicit dimensions and approaches, it is indicated that the PE constitutes a powerful theoretical and methodological path for health education from the perspective of good living and human emancipation. (AU)

Challenges in telemedicine for adult patients with drug-resistant epilepsy undergoing ketogenic diet treatment during the COVID-19 pandemic in the public healthcare system in Brazil.

Hygienic and sanitary measures and social distancing policies implemented during the new coronavirus disease - COVID-19 - pandemic have altered the care and follow-up provided by healthcare professionals for patients with chronic diseases, including patients with epilepsy (PWEs). Telemedicine has become a solution for the healthcare of PWEs in many developed countries. In this short communication, we trace a particular perspective for the application of telemedicine for PWEs undergoing ketogenic diet (KD) treatment, considering the social and economic difficulties faced by healthcare teams in resource-poor countries, such as Brazil. During the pandemic, financial strain was the main impediment to following KD. The pandemic increased socioeconomic insecurity and access to KD-related products, as well as increasing anxiety in 71% of PWE, impacting their KD treatment follow-up. The challenges of telemedicine in Brazil include not only social and economic issues but also access to food, healthcare services, and education for the population, in addition to digital inclusion.

National TB program shortages as potential factor for poor-quality TB care cascade: healthcare workers' perspective from Beira, Mozambique

Background Mozambique is one of the countries with the deadly implementation gaps in the tuberculosis (TB) care and services delivery. In-hospital delays in TB diagnosis and treatment, transmission and mortality still persist, in part, due to poor-quality of TB care cascade. Objective We aimed to assess, from the healthcare workers' (HCW) perspective, factors associated with poor-quality TB care cascade and explore local sustainable suggestions to improve inhospital TB management. Methods In-depth interviews and focus group discussions were conducted with different categories of HCW. Audio-recording and written notes were taken, and content analysis was performed through atlas.ti7. Results Bottlenecks within hospital TB care cascade, lack of TB staff and task shifting, centralized and limited time of TB laboratory services, and fear of healthcare workers getting infected by TB were mentioned to be the main factors associated with implementation gaps. Interviewees believe that task shifting from nurses to hospital auxiliary workers, and from higher and well-trained to lower HCW are accepted and feasible. The expansion and use of molecular TB diagnostic tools are seen by the interviewees as a proper way to fight effectively against both sensitive and MDR TB. Ensuring provision of N95 respiratory masks is believed to be an essential requirement for effective engagement of the HCW on high-quality in-hospital TB care. For monitoring and evaluation, TB quality improvement teams in each health facility are considered to be an added value. Conclusion Shortage of resources within the national TB control programme is one of the potential factors for poor-quality of the TB care cascade. Task shifting of TB care and services delivery, decentralization of the molecular TB diagnostic tools, and regular provision of N95 respiratory masks should contribute not just to reduce the impact of resource scarceness, but also to ensure proper TB diagnosis and treatment to both sensitive and MDR TB.

Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study.

BACKGROUND: Diabetes has been associated with increased COVID-19-related mortality, but the association between modifiable risk factors, including hyperglycaemia and obesity, and COVID-19-related mortality among people with diabetes is unclear. We assessed associations between risk factors and COVID-19-related mortality in people with type 1 and type 2 diabetes. METHODS: We did a population-based cohort study of people with diagnosed diabetes who were registered with a general practice in England. National population data on people with type 1 and type 2 diabetes collated by the National Diabetes Audit were linked to mortality records collated by the Office for National Statistics from Jan 2, 2017, to May 11, 2020. We identified the weekly number of deaths in people with type 1 and type 2 diabetes during the first 19 weeks of 2020 and calculated the percentage change from the mean number of deaths for the corresponding weeks in 2017, 2018, and 2019. The associations between risk factors (including sex, age, ethnicity, socioeconomic deprivation, HbA1c, renal impairment [from estimated glomerular filtration rate (eGFR)], BMI, tobacco smoking status, and cardiovascular comorbidities) and COVID-19-related mortality (defined as International Classification of Diseases, version 10, code U07.1 or U07.2 as a primary or secondary cause of death) between Feb 16 and May 11, 2020, were investigated by use of Cox proportional hazards models. FINDINGS: Weekly death registrations in the first 19 weeks of 2020 exceeded the corresponding 3-year weekly averages for 2017-19 by 672 (50·9%) in people with type 1 diabetes and 16 071 (64·3%) in people with type 2 diabetes. Between Feb 16 and May 11, 2020, among 264 390 people with type 1 diabetes and 2 874 020 people with type 2 diabetes, 1604 people with type 1 diabetes and 36 291 people with type 2 diabetes died from all causes. Of these total deaths, 464 in people with type 1 diabetes and 10 525 in people with type 2 diabetes were defined as COVID-19 related, of which 289 (62·3%) and 5833 (55·4%), respectively, occurred in people with a history of cardiovascular disease or with renal impairment (eGFR <60 mL/min per 1·73 m2). Male sex, older age, renal impairment, non-white ethnicity, socioeconomic deprivation, and previous stroke and heart failure were associated with increased COVID-19-related mortality in both type 1 and type 2 diabetes. Compared with people with an HbA1c of 48-53 mmol/mol (6·5-7·0%), people with an HbA1c of 86 mmol/mol (10·0%) or higher had increased COVID-19-related mortality (hazard ratio [HR] 2·23 [95% CI 1·50-3·30, p<0·0001] in type 1 diabetes and 1·61 [1·47-1·77, p<0·0001] in type 2 diabetes). In addition, in people with type 2 diabetes, COVID-19-related mortality was significantly higher in those with an HbA1c of 59 mmol/mol (7·6%) or higher than in those with an HbA1c of 48-53 mmol/mol (HR 1·22 [95% CI 1·15-1·30, p<0·0001] for 59-74 mmol/mol [7·6-8·9%] and 1·36 [1·24-1·50, p<0·0001] for 75-85 mmol/mol [9·0-9·9%]). The association between BMI and COVID-19-related mortality was U-shaped: in type 1 diabetes, compared with a BMI of 25·0-29·9 kg/m2, a BMI of less than 20·0 kg/m2 had an HR of 2·45 (95% CI 1·60-3·75, p<0·0001) and a BMI of 40·0 kg/m2 or higher had an HR of 2·33 (1·53-3·56, p<0·0001); the corresponding HRs for type 2 diabetes were 2·33 (2·11-2·56, p<0·0001) and 1·60 (1·47-1·75, p<0·0001). INTERPRETATION: Deaths in people with type 1 and type 2 diabetes rose sharply during the initial COVID-19 pandemic in England. Increased COVID-19-related mortality was associated not only with cardiovascular and renal complications of diabetes but, independently, also with glycaemic control and BMI. FUNDING: None.

National trends in incidence, mortality, hospitalizations, and expenditures for pemphigus in Taiwan.

BACKGROUND: Data on trends in epidemiological characteristics and economic burden of pemphigus are scarce. OBJECTIVE: To describe national trends in pemphigus' incidence, mortality, hospitalizations, and expenditures between 2003 and 2015 in Taiwan. METHODS: This nationwide study used the Taiwan National Health Insurance Research Database to identify pemphigus patients from 2003 to 2015. Annual incidence, prevalence, healthcare utilization, and expenditure trends were calculated and analyzed. RESULTS: Pemphigus' incidence increased significantly from 3.19 to 4.70 per million person-years in 2003-2010 but fluctuated in 2011-2015. Pemphigus patients had higher mortality and care costs. Medical utilization and expenditure declined for pemphigus inpatients and outpatients. Systemic corticosteroid use decreased, but mortality remained stable. CONCLUSION: The health expense reduction for pemphigus was mainly attributed to decreased utilization, length of stay, and inpatient costs. The persistently elevated mortality rate highlights an unmet need in pemphigus therapy.

Causes of death in clozapine-treated patients in a catchment area: a 10-year retrospective case-control study.

Uncertainty regarding the excess of mortality in patients treated with clozapine persists. A decrease in all-cause mortality, and perhaps also in suicide, after clozapine initiation has been reported, but there are no studies in which preventable causes were ascertained in those taking medication in the long term. Here, we aimed to assess a decade of causes of deaths in a catchment area in patients with schizophrenia chronically treated with clozapine and compared them to a clozapine-treated control cohort. Causes of deaths were classified as suicide, expected (e.g. cancer), and unexpected deaths (encompassing causes of death potentially due to clozapine side effects, and unexplained sudden death). We used descriptive statistics for comparing socio-demographic and clinical factors between the three groups. Logistic regression models were used to examine risk factors associated with unexpected death compared to the control group. We found that the overall mortality was similar to that in previous studies (at 0.8% yearly on average) with unexpected deaths accounting for 52% of total deaths. The unexpected deaths group was on average treated with higher clozapine doses (mean 460 mg/day). A small but significant peak of unexpected deaths was found during the 2018 summer heat wave, which might have exacerbated dose-dependent side effects of clozapine. We suggest increased monitoring for those on higher doses of clozapine as one potential intervention to decrease mortality in this population.

Increased risk of tinnitus following a trigeminal neuralgia diagnosis: a one-year follow-up study.

BACKGROUND: Tinnitus due to hyperactivity across neuronal ensembles along the auditory pathway is reported. We hypothesized that trigeminal neuralgia patients may subsequently suffer from tinnitus. Using nationwide, population-based data and a retrospective cohort study design, we investigated the risk of tinnitus within 1 year following trigeminal neuralgia. METHODS: We used the Taiwan National Health Insurance Research Dataset, a claims database, to identify all patients diagnosed with trigeminal neuralgia from January 2001 to December 2014, 12,587 patients. From the remaining patients, we identified 12,587 comparison patients without trigeminal neuralgia by propensity score matching, using sex, age, monthly income, geographic region, residential urbanization level, and tinnitus-relevant comorbidities (hyperlipidemia, diabetes, coronary heart disease, hypertension, cervical spondylosis, temporomandibular joint disorders and injury to head and neck and index year). All study patients (n = 25,174) were tracked for a one-year period to identify those with a subsequent diagnosis of tinnitus over 1-year follow-up. RESULTS: Among total 25,174 sample patients, the incidence of tinnitus was 18.21 per 100 person-years (95% CI = 17.66 ~ 18.77), the rate being 23.57 (95% CI = 22.68 ~ 24.49) among patients with trigeminal neuralgia and 13.17 (95% CI = 12.53 ~ 13.84) among comparison patients. Furthermore, the adjusted Cox proportional hazard ratio for tinnitus in the trigeminal neuralgia group was 1.68 (95% CI = 1.58 ~ 1.80) relative to the comparison cohort. CONCLUSIONS: We found a significantly increased risk of tinnitus within 1 year of trigeminal neuralgia diagnosis compared to those without the diagnosis. Further studies in other countries and ethnicities are needed to explore the relationship between trigeminal neuralgia and subsequent tinnitus.

Direct and indirect costs of cluster headache: a prospective analysis in a tertiary level headache centre.

BACKGROUND: Cluster headache (CH) is the most frequent trigemino-autonomic cephalgia. CH can manifest as episodic (ECH) or chronic cluster headache (CCH) causing significant burden of disease and requiring attack therapy and prophylactic treatment. The few data available on the economic burden of CH come from retrospective studies based on questionnaires, population surveys and medical insurance claims database. Although all these studies showed an important economic burden, they provided different estimates depending on variability of CH awareness and management, healthcare systems, available therapies and use of treatments according to different guidelines. METHODS: This prospective study aimed to quantify the total direct and indirect cost of ECH and CCH over a cluster period, both for the patient and for the National Health System (NHS), using data from subjects who consecutively attended an Italian tertiary headache centre between January 1, 2018 and December 31, 2018. RESULTS: A total 108 patients (89 ECH, 19 CCH) were included. Mean attack frequency was 2.3 ± 1.4 per day. Mean total cost of a CH bout was €4398 per patient and total cost of CCH was 5.4 times higher than ECH (€13,350 vs. €2487, p <  0.001). Direct costs represented the 72.1% of total cost and were covered for the 94.8% by the NHS. The costs for any item of expense were higher for CCH than for ECH (p <  0.001). Mean indirect costs for a CH bout were €1226 per patient and were higher for CCH compared to ECH (€3.538 vs. €732), but the difference was not significant. Days with reduced productive capacity impacted for the 64.6% of the total indirect costs. The analysis of the impact CH on work showed that 27%% of patients felt that CH had limited their career, 40% had changed their work pattern, 20% had changed their place of employment and 10% had lost a job due to the disease. CONCLUSION: Our results provide a valuable estimate of the direct and indirect costs of ECH and CCH in the specific setting of a tertiary headache centre and confirm the high economic impact of CH on both the NHS and patients.

COVID-19 in Brazil: advantages of a socialized unified health system and preparation to contain cases.

The outbreak of new coronavirus disease 2019 (COVID-19) reported for the first time in Wuhan, China in late December 2019 have rapidly spread to other countries and it was declared on January 30, 2020 as a public health emergency of international concern (PHEIC) by the World Health Organization. Before the first COVID-19 cases were reported in Brazil, several measures have been implemented including the adjustment of legal framework to carry out isolation and quarantine. As the cases increased significantly, new measures, mainly to reduce mortality and severe cases, have also been implemented. Rapid and robust preparedness actions have been undertaken in Brazil while first cases have not yet been identified in Latin-American. The outcome of this early preparation should be analyzed in future studies.