Disease burden and economic impact of diagnosed non-alcoholic steatohepatitis in five European countries in 2018: A cost-of-illness analysis.

BACKGROUND AND AIMS: Non-alcoholic steatohepatitis (NASH) is a chronic disease that can progress to end-stage liver disease (ESLD). A large proportion of early-stage NASH patients remain undiagnosed compared to those with advanced fibrosis, who are more likely to receive disease management interventions. This study estimated the disease burden and economic impact of diagnosed NASH in the adult population of France, Germany, Italy, Spain and the United Kingdom in 2018. METHODS: The socioeconomic burden of diagnosed NASH was estimated using cost-of-illness methodology applying a prevalence approach to estimate the number of adults with NASH and the attributable economic and wellbeing costs. Given undiagnosed patients do not incur costs in the study, the probability of diagnosis is central to cost estimation. The analysis was based on a literature review, databases and consultation with clinical experts, economists and patient groups. RESULTS: The proportion of adult NASH patients with a diagnosis ranged from 11.9% to 12.7% across countries, which increased to 38.8%-39.1% for advanced fibrosis (F3-F4 compensated cirrhosis). Total economic costs were €8548-19 546M. Of these, health system costs were €619-1292M. Total wellbeing costs were €41 536-90 379M. The majority of the undiagnosed population (87.3%-88.2% of total prevalence) was found to have early-stage NASH, which, left untreated, may progress to more resource consuming ESLD over time. CONCLUSIONS: This study found that the majority of economic and wellbeing costs of NASH are experienced in late disease stages. Earlier diagnosis and care of NASH patients could reduce future healthcare costs.

Supporting caregivers of children living with disability in a humanitarian context: realist-informed evaluation of the 'Mighty Children' programme in Afghanistan.

INTRODUCTION: To ensure that humanitarian action is disability-inclusive, evidence is needed to understand how different strategies to support children living with disabilities and their families can work in these settings. Evidence from other contexts suggests support groups can improve caregiver quality of life (QOL). This study reports an evaluation of the 'Mighty Children' programme a participatory educational support group programme for caregivers of children living with disability in Kabul province, Afghanistan. METHODS: We conducted a mixed-methods realist-informed before-and-after study to measure change in caregiver-reported QOL and explore how and for whom the programme worked, and in what contexts. Female caregivers of children with any disability were recruited through clinics in urban Kabul (n=3) and rural Paghman district (n=3). We collected quantitative data on QOL pre/post programme using the Paediatric Quality of Life Inventory Family Impact Module (PedsQL-FIM). Qualitative data were collected through facilitator and participant focus groups postprogramme. RESULTS: 118 caregivers participated in two cohorts (November 2020, February 2021). Caregivers expressed a significant increase in QOL from baseline to programme completion (t(125)=-10.7, p≤0.0001). Participation in cohort 2 was associated with the greatest PedsQL-FIM change.Qualitative data revealed positive changes postprogramme in five key areas: caregiver mindset, parenting practices, disability-inclusive behaviours, psychological well-being and child functioning. These changes were seen as both outcomes and mechanisms influencing the primary outcome of QOL. Mechanisms that mediated these changes included increased knowledge of disability and the core acceptance and commitment therapy components of mindfulness and acceptance. CONCLUSION: The Mighty Children caregiver support programme for children living with disability in Afghanistan was associated with improved caregiver QOL. Further studies are warranted to explore pathways to scale, sustainability and potential application in other settings.

Antimicrobial resistance profiles of bacteria associated with lower respiratory tract infections in cats and dogs in England.

BACKGROUND: Bacterial lower respiratory tract infections (bLRTIs) are common and potentially life threatening in cats and dogs. Antibiotic treatment is often initiated before the diagnosis of bLRTI; therefore improved knowledge of the aetiology and antibiotic susceptibility patterns of these infections is essential to inform empiric antibiotic choices. METHODS: A retrospective study of microbiological, cytological results and their drug susceptibilities from lower respiratory samples (n = 1989) processed in a UK commercial laboratory between 2002 and 2012 was carried out. RESULTS: Thirty-nine per cent of feline samples and 50% of canine samples were positive for bacterial growth with most yielding a single organism (72 % and 69%, respectively). Bordetella bronchiseptica (20.2% from dogs and 2.3% from cats), Pasteurella spp. (23.2%, 31.8%), E. coli (16.2%, 13.6%) and Pseudomonas spp. (11.1%, 11.4%) were most frequently isolated from cytologically positive samples which contained intracellular bacteria (10%, 14%). Amoxycillin-clavulanate, cephalothin, cefovecin, oxytetracycline and trimethoprim/sulfamethoxazole showed modest in vitro activity against E. coli from dogs (approximately 70% susceptibility). Pseudomonas spp. were resistant to enrofloxacin (50%), ticarcillin (25%) and marbofloxacin (13%) but showed lower or zero resistance to aminoglycosides (approximately 7%) and ciprofloxacin (0%). Multi drug resistance (acquired resistance to three or more antimicrobial drug classes) was particularly common among E. coli isolates, with 23% from feline samples and 43% from canine samples. CONCLUSION: Resistance to certain first-choice antibiotics was detected in bLRTIs highlighting the need for continued monitoring and sound evidence to inform decision-making in the management of these infections.

Feasibility of single question mental health surveillance in chronic disease.

OBJECTIVE: To determine the (1) feasibility and acceptability of administering single question mental health surveillance to carers of children with chronic disease in the inpatient setting and (2) sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of this question to detect 'at risk' children compared with the Strengths and Difficulties Questionnaire (SDQ). DESIGN: Cross-sectional pilot SETTING: Day Medical Unit of a tertiary paediatric hospital, 1 April 2021-31 July 2021. PATIENTS: Carers of children aged 2-17 years with chronic medical conditions. INTERVENTIONS: Caregivers were asked to respond to 'Thinking about your child's mental health over the past 4 weeks, are they thriving/coping/struggling/always overwhelmed?' during the admission process. All carers and children 11-17 years were invited to complete the SDQ. MAIN OUTCOME MEASURES: Feasibility and acceptability were determined by nursing feedback. Sensitivity, specificity, PPV and NPV were determined by comparing question responses with clinical cut-points on the SDQ. RESULTS: 213 carers responded to the question. Nurses reported that the question was easy (12/14) or moderately easy (2/14) to use and was 'easily understood' (6/14) or 'understood after some explanation' (8/14) for most carers. The question demonstrated a high specificity (0.98)/PPV (0.87) but low sensitivity (0.2) when thriving/coping were considered together whereas when thriving was compared with all other responses the sensitivity increased to 0.7. CONCLUSIONS: Single question mental health surveillance appears acceptable to carers and nursing staff and has a high level of specificity for children who are 'struggling' or 'always overwhelmed' versus the SDQ screening measure.

Disease burden and economic impact of diagnosed non-alcoholic steatohepatitis (NASH) in the United Kingdom (UK) in 2018.

BACKGROUND AND AIMS: Non-alcoholic steatohepatitis (NASH) - a progressive subset of non-alcoholic fatty liver disease (NAFLD) - is a chronic liver disease that can progress to advanced fibrosis, cirrhosis, and end-stage liver disease (ESLD) if left untreated. Early-stage NASH is usually asymptomatic, meaning a large proportion of the prevalent population are undiagnosed. Receiving a NASH diagnosis increases the probability that a patient will receive interventions for the purpose of managing their condition. The purpose of this study was to estimate the disease burden and economic impact of diagnosed NASH in the United Kingdom (UK) adult population in 2018. METHODS: The socioeconomic burden of diagnosed NASH from a societal perspective was estimated using cost-of-illness methodology applying a prevalence approach. This involved estimating the number of adults with diagnosed NASH in the UK in a base period (2018) and the economic and wellbeing costs attributable to diagnosed NASH in that period. The analysis was based on a targeted review of the scientific literature, existing databases and consultation with clinical experts, health economists and patient groups. RESULTS: Of the prevalent NASH population in the UK in 2018, an estimated 79.8% were not diagnosed. In particular, of the prevalent population in disease stages F0 to F2, only 2.0% (F0), 2.0% (F1) and 16.5% (F2), respectively, were diagnosed. Total economic costs of diagnosed NASH in the UK ranged from £2.3 billion (lower prevalence scenario, base probability of diagnosis scenario) to £4.2 billion (higher prevalence scenario, base probability of diagnosis scenario). In 2018, people with NASH in the UK were estimated to experience 94,094 to 174,564 disability-adjusted life years (DALYs) overall. Total wellbeing costs associated with NASH in 2018 were estimated to range between £5.6 to £10.5 billion. CONCLUSION: The prevention and appropriate management of adult NASH patients could result in reduced economic costs and improvements in wellbeing.

Generating Real-World Evidence on the Quality Use, Benefits and Safety of Medicines in Australia: History, Challenges and a Roadmap for the Future.

Australia spends more than $20 billion annually on medicines, delivering significant health benefits for the population. However, inappropriate prescribing and medicine use also result in harm to individuals and populations, and waste of precious health resources. Medication data linked with other routine collections enable evidence generation in pharmacoepidemiology; the science of quantifying the use, effectiveness and safety of medicines in real-world clinical practice. This review details the history of medicines policy and data access in Australia, the strengths of existing data sources, and the infrastructure and governance enabling and impeding evidence generation in the field. Currently, substantial gaps persist with respect to cohesive, contemporary linked data sources supporting quality use of medicines, effectiveness and safety research; exemplified by Australia's limited capacity to contribute to the global effort in real-world studies of vaccine and disease-modifying treatments for COVID-19. We propose a roadmap to bolster the discipline, and population health more broadly, underpinned by a distinct capability governing and streamlining access to linked data assets for accredited researchers. Robust real-world evidence generation requires current data roadblocks to be remedied as a matter of urgency to deliver efficient and equitable health care and improve the health and well-being of all Australians.

Antibiotic resistance in bacteria associated with equine respiratory disease in the United Kingdom.

INTRODUCTION: Respiratory diseases account for the highest number of clinical problems in horses compared with other body systems. While microbiological culture and sensitivity testing is essential for certain cases, knowledge of the most likely bacterial agents and their susceptibilities is necessary to inform empirical antibiotic choices. METHODS: A retrospective study of microbiological and cytological results from upper and lower respiratory samples (n=615) processed in a commercial laboratory between 2002 and 2012 was carried out. A further study of lower respiratory samples from horses with clinical signs of lower respiratory disease from May to June 2012 was undertaken. RESULTS: Both studies revealed Streptococcus equi subspecies zooepidemicus, Pseudomonas aeruginosa, Pasteurella species, Escherichia coli and Bordetella bronchiseptica as the most frequently isolated species. S equi subspecies zooepidemicus and subspecies equi were susceptible to ceftiofur (100 per cent) and erythromycin (99 per cent). Resistance to penicillin (12.5 per cent of S equi subspecies equi from upper respiratory tract samples) and tetracycline (62.7 per cent) was also detected. Gram-negative isolates showed resistance to gentamicin, trimethoprim-sulfamethoxazole and tetracycline but susceptibility to enrofloxacin (except Pseudomonas species, where 46.2 per cent were resistant). Multiple drug resistance was detected in 1 per cent of isolates. CONCLUSION: Resistance to first-choice antibiotics in common equine respiratory tract bacteria was noted and warrants continued monitoring of their susceptibility profiles. This can provide information to clinicians about the best empirical antimicrobial choices against certain pathogenic bacteria and help guide antibiotic stewardship efforts to converse their efficacy.

Can scuba diving offer therapeutic benefit to military veterans experiencing physical and psychological injuries as a result of combat? A service evaluation of Deptherapy UK.

Purpose: To explore the effectiveness of scuba diving in providing therapeutic and rehabilitative benefit to ex-service personnel who have experienced traumatic physical and/or psychological injuries resulting from combat.Methods: This study took the form of a service evaluation of Deptherapy, a UK-based niche charity offering support to military veterans who have experienced life-changing injuries. Deptherapy provides scuba diving qualifications, consisting of theory and practical diving experience, to participants alongside a Peer Support Buddy scheme that provides continuing support to servicemen involved with the charity. A total of 15 male veterans were invited to take part in the study. The methodology comprised retrospective and current quantitative measures of mental well-being and functional ability, utilising the General Health Questionnaire-28, and subsequent semi-structured interviews with participants, their families and health professionals.Results: Participants reported an improvement in levels of anxiety, depression and social functioning, and a reduction in insomnia, following their involvement in organised scuba diving activities. There was a mean average difference of 14.3 points improvement on the General Health Questionnaire-28 scale variants between prior interaction with Deptherapy and current perceptions following engagement with the programme. The positive perceptions, as indicated from the semi-structured interviews, were more pronounced in those whose injuries were predominantly psychological, rather than physical.Conclusion: Scuba diving can offer significant therapeutic benefits, particularly for ex-military amputees experiencing co-morbid anxiety and/or chronic psychological adjustment disorders, notably in terms of improvements in social dysfunction and symptomology of depression.Implications for Rehabilitation Scuba Diving as a TherapyMilitary combat can result in devastating, chronic physical and/or psychological injury.Current research suggests that a combination of medical and psychological therapy may prove to be the most beneficial for military veterans.Scuba diving has the potential to benefit injured veterans due the requirement of complete focus and the feeling of weightlessness when underwater.This article evaluates whether scuba diving is an effective physical and psychological therapy through GHQ-28 analysis and veteran interviews.Scuba diving benefited injured veterans in terms of chronic pain relief and depression symptoms alleviation.

Assessing Quality of Pharmacist-Led Education for Patients with COPD Using the Lung Information Needs Questionnaire: A Pilot Study.

BACKGROUND: Transitioning a patient from the hospital to home is an area of vulnerability for patients with Chronic Obstructive Pulmonary Disease (COPD). Patients with COPD frequently readmit as they often do not understand their disease state, medications or when to seek medical attention. OBJECTIVES: The objective of this study is to determine the impact that pharmacist-led education has on a patient's understanding of their disease state by assessing the results of the Lung Information Needs Questionnaire (LINQ). METHODS: This study uses a quasi-experimental design to formally assess pharmacist-led education provided to patients with COPD using the LINQ. The LINQ was used to assess knowledge of the disease state and medications before and after receiving education on disease state management, smoking cessation and proper medication use. RESULTS: A total of 17 patients completed the LINQ. The survey results showed a statistically significant improvement in patient understanding in 4 of the 6 targeted areas. CONCLUSION: Results from the formal assessment using the LINQ suggest that pharmacist-lead education for COPD patients is beneficial and reliable. This study presents a continued need for patient education and research in this high-risk patient population.

Rapid and substantial increases in anticoagulant use and expenditure in Australia following the introduction of new types of oral anticoagulants.

OBJECTIVES: To quantify changes in anticoagulant use in Australia since the introduction of Non-vitamin K antagonist anticoagulants (NOACs) and to estimate government expenditure. DESIGN: Interrupted-time-series analysis quantifying anticoagulant dispensing, before and after first Pharmaceutical Benefits Scheme (PBS) NOAC listing in August 2009 for venous thromboembolism prevention; and expanded listing for stroke prevention in non-valvular atrial fibrillation (AF) in August 2013, up to June 2016. Estimated government expenditure on PBS-listed anticoagulants. SETTING AND PARTICIPANTS: PBS dispensing in 10% random sample of Australians, restricted to continuous concessional beneficiaries dispensed oral anticoagulants from July 2005 to June 2016. Total PBS anticoagulant expenditure was calculated using Medicare Australia statistics. MAIN OUTCOME MEASURES: Monthly dispensing and initiation of oral anticoagulants (warfarin, rivaroxaban, dabigatran or apixaban). Annual PBS anticoagulant expenditure. RESULTS: An estimated 149,180 concessional beneficiaries were dispensed anticoagulants (100% warfarin) during July 2005. This increased to 292,550 during June 2016, of whom 47.0%, 27.1%, 18.7% and 7.2% were dispensed warfarin, rivaroxaban, apixaban and dabigatran, respectively. Of 16,500 initiated on anticoagulants in June 2016, 24.3%, 38.2%, 30.0% and 7.5% were initiated on warfarin, rivaroxaban, apixaban, and dabigatran, respectively. Compared to July 2005-July 2013, from August 2013-June 2016, dispensings for all anticoagulants increased by 2,303 dispensings/month (p<0.001, 95%CI = [1,229 3,376]); warfarin dispensing decreased by 1,803 dispensings/month (p<0.001, 95%CI = [-2,606, -1,000]). Total PBS anticoagulant expenditure was $19.5 million (97.0% concessional) in 2008/09, of which 100% was warfarin and $203.3 million (86.2% concessional) in 2015/16, of which 11.2% was warfarin. CONCLUSIONS: The introduction of the NOACs led to substantial increases in anticoagulant use and expenditure in Australia.

When is too little care, too much harm in cystic fibrosis? Psychological and ethical approaches to the problem.

Some parents of children with cystic fibrosis (CF) do not adhere to treatments recommended by the CF team. This can be a challenging issue for CF clinicians and can create conflict between the parents and treating team. Both parents and treating team believe they are acting in the best interests of the child, but do not share a common opinion as to what that entails. In this paper we present an understanding of the psychological framework of parents' illness representation that may foster a better understanding by CF clinicians of how to approach parents who hold a conflicting opinion regarding optimal care. Continuing to work with families towards optimal care is a moral obligation, but the key ethical decision is when to intervene to protect the child. In this paper we introduce the concept of the zone of parental discretion as an ethical tool to help decide the best way forward when parents do not accept medical advice on the optimal care of their child with CF.

An unusual presentation of mastocytosis: unilateral swelling of the vulva.

Mastocytosis is a primary, abnormal accumulation of mast cells associated with a broad range of local and systemic symptoms. We report two female adolescents with episodic, unilateral, swelling of the labia majora that was discovered to be an unusual presentation of mastocytosis. Mastocytosis is frequently misdiagnosed because of its rarity and variable clinical presentation, which often mimics other conditions. In the appropriate setting, mastocytosis should be included in the differential diagnosis of labium majus swelling.