Experiences of health professionals in EU institutions during the Covid crisis

We performed a quantitative and a qualitative study, addressing the experiences of health services of 16 European Union institutions during the Covid-19 pandemic. Among the 165 eligible subjects, 114 (69%) participated in the survey. The biggest problem reported was limitation of social contacts (53%). At work, the biggest problems were workload (50%) and shortage of staff (37%). The majority were positive about teamwork. Teleworking was seen positively by 81%. Most participants felt better prepared for future situations by their recent experience (94%). Participants underlined the importance of strengthening the collaboration with the local health systems (80%), as well as with medical services and internal services within their own institution (75%). The qualitative analysis also reported participants' fear of becoming infected, and of their family members getting sick. Similarly reported were the sense of isolation and anxiety, the excessive workload and work complexity, shortage of staff, and the benefits of teleworking. Study findings highlight: i) the need to strengthen mental health support to health personnel, not only during crisis situations; ii) the need for sufficient health workers, with swift recruitment strategies in times of crisis; iii) the importance of clear protocols to ensure no shortages of personal protective equipment (PPE); iv) the importance of teleworking, which represents an opportunity for major reorganisation of work within EU medical services; v) the need to strengthen collaboration with local health systems and the medical services of EU institutions.

International medical electives in Sub-Saharan Africa: experiences from a 19-year NGO-driven initiative

BACKGROUND

Mainstream medical education remains largely focused on national health issues. Therefore, in order to expose medical students to international health issues, it is beneficial to facilitate international medical electives.

METHODS

This article describes the Junior Project Officer (JPO) program, a medical experience based on clinical electives in Sub-Saharan Africa, supported by a Non-Governmental Organisation (NGO). Residents spend 6 months as part of a multidisciplinary medical team in Africa. A post-elective online survey was administered to all who participated in the program in the period 2002-2020. The questionnaire comprised three domains: (i) general and pre-departure information; (ii) the experience; (iii) the post-experience.

RESULTS

Questionnaires were received from 157/241 subjects, a response rate of 65%. The most common specialties were pediatrics, public health, and internal medicine. Of all, 87% carried out clinical activities; 45% also worked in the management of health services, and 60% carried out research activities. About 64% reported difficulties linked to a lack of equipment, different ways of working (57%), and exposure to situations for which they did not feel technically prepared (56%). In 25% of cases, residents reported that their school's attitude to their doing the elective was not positive: upon their return, over 50% felt that their experience was not sufficiently valued by their institution. Respondents considered the experience important for professional and personal growth (93% and 80% respectively ). Forty-two participants (27%) reported that the experience had a significant impact on their future career choices.

CONCLUSION

Despite the difficulties encountered, a well-structured experience in international health can have a positive impact on residents, professionally and personally. Key factors behind the positive outcomes are the substantial length (6 months) of the experience, and the long term working relationships between the sending and receiving institutions. The schools in Italy that provide the students for the electives need to see more evidence that international electives are worth the investment.

The impact of the COVID-19 pandemic on health service use in sub-Saharan Africa

SETTING: Six hospitals in four sub-Saharan African countries.OBJECTIVE: To examine the indirect effects of COVID-19 on health service utilisation and to explore the risk of bias in studies on prediction models.DESIGN: Monthly data were analysed using interrupted time-series modelling. We used linear mixed-effect models for the analysis of antenatal care visits, institutional deliveries, vaccinations, outpatient visits and hospital admissions, and generalised linear mixed-effect models for hospital mortality.RESULTS: During 2018–2020, the six hospitals recorded a total of 57,075 antenatal care visits, 38,706 institutional deliveries, 312,961 vaccinations, 605,925 out-patient visits and 143,915 hospital admissions. The COVID-19 period was associated with decreases in vacci-nations (− 575 vaccinations, P < 0.0001), outpatient visits (− 700 visits, P < 0.0001) and hospital admission (− 102 admission, P = 0.001); however, no statistically significant effects were found for antenatal care visits (P = 0.71) or institutional deliveries (P = 0.14). Mortality rate increased by 2% per month in the pre-COVID-19 period; however, a decreasing trend (by 2% per month) was observed during the COVID-19 period (P = 0.004). Subgroup and sensitivity analyses broadly confirmed the main findings with only minor inconsistencies. A reduction in outpatient visits was also observed in hospitals from countries with a higher Stringency Index and in urban hospitals.CONCLUSIONS: The pandemic resulted in a reduction in health service utilisation. The decreases were less than anticipated from modelling studies.

Lights and Shadows of Cerebrospinal Fluid Biomarkers in the Current Alzheimer's Disease Framework

BACKGROUND

The most significant biomarkers that are included in the Alzheimer's disease (AD) research framework are amyloid-β plaques deposition, p-tau, t-tau, and neurodegeneration.Although cerebrospinal fluid (CSF) biomarkers are included in the most recent AD research criteria, their use is increasing in the routine clinical practice and is applied also to the preclinical phases of AD, including mild cognitive impairment. The role of these biomarkers is still unclear concerning the preclinical stage of AD diagnosis, the CSF methodology, and the costs-benefits of the biomarkers' tests. The controversies regarding the use of biomarkers in the clinical practice are related to the concepts of analytical validity, clinical validity, and clinical utility and to the question of whether they are able to diagnose AD without the support of AD clinical phenotypes.

OBJECTIVE

The objective of the present work is to expose the strengths and weaknesses of the use of CSF biomarkers in the diagnosis of AD in a clinical context.

METHODS

We used PubMed as main source for articles published and the final reference list was generated on the basis of relevance to the topics covered in this work.

RESULTS

The use of CSF biomarkers for AD diagnosis is certainly important but its indication in routine clinical practice, especially for prodromal conditions, needs to be regulated and also contextualized considering the variety of possible clinical AD phenotypes.

CONCLUSION

We suggest that the diagnosis of AD should be understood both as clinical and pathological.

Medical Electives in Sub-Saharan Africa: A 15-Year Student/NGO-Driven Initiative

Medical schools are developing global health programmes, and medical students are requesting global health training and creating opportunities when these are not provided by medical schools. This article described the Wolisso Project (WP), a medical experience on clinical electives in Sub-Saharan Africa, driven by a collaboration between a student organisation and a Nongovernmental Organization (NGO). Preclinical medical students spent 4 weeks as part of a multidisciplinary medical team in Africa. Post-elective questionnaires were administered to all subjects who participated in the project. Of all, 141 students responded to the questionnaire. The participants came from 30 Italian universities. The main difficulties reported are due to the lack of resources for the exercise of the medical activity, and difficulties related to language and communication. The African experience had a positive impact on the progress of the studies upon return, with an increase in determination and motivation. The experience had also positive influences on the future professional choices and carriers. The experience seems to contribute not only to the professional growth, but also to the personal development. A key factor in the positive outcomes of this experience is it being implemented by an NGO with long-term working relationships with the African populations. Another is that the project is carried out in health facilities where NGO staff have been working for a long time. These factors reduce the potential risks connected with this type of experience. They ensure a satisfactory level of supervision, the lack of which has been a serious problem in many similar experiences. A well-structured, mentored experience in international health can have a positive impact on preclinical students' attitudes, including their compassion, volunteerism, and interest in serving underserved populations. Only a small number of Italian universities facilitate pre-graduate medical elective experiences in LMICs. The WP seems to be attempting to compensate for the lack of international experience in LMICs offered by universities. Italian medical schools should incorporate changes in their curricula to train socially responsible physicians.

Views of European Drug Development Stakeholders on Treatment Optimization and Its Potential for Use in Decision-Making

Background

The current drug development paradigm has been criticized for being too drug-centered and for not adequately focusing on the patients who will eventually be administered the therapeutic interventions it generates. The drug-driven nature of the present framework has led to the emergence of a research gap between the pre-approval development of anticancer medicines and their post-registration use in real-life clinical practice. This gap could potentially be bridged by transitioning toward a patient-centered paradigm that places a strong emphasis on treatment optimization, which strives to optimize the way health technologies are applied in a real-world environment. However, questions remain concerning the ideal features of treatment optimization studies and their acceptability among key stakeholders.

Objectives

The aim of this study was to explore the views of key stakeholders in the drug development process regarding the concept of treatment optimization.

Methods

Semi-structured interviews were conducted between December 2018 and May 2019 with 26 participants across ten EU Member States and six different stakeholder groups, including academic clinicians as well as representatives of patient organizations, regulatory authorities, health technology assessment agencies, payers, and industry.

Results

Based on the input of the experts interviewed, clarification was obtained regarding the optimal features of treatment optimization studies in terms of their conduct, funding, timing, design, and setting. Moreover, a number of opportunities and challenges of undertaking such trials were identified. Inter-stakeholder discussion during their design was seen as desirable. There was also broad support among the participants for regulatory measures to facilitate treatment optimization, although there was no agreement on the optimal scale and nature of these initiatives. Furthermore, the interviewees believed that the evidence strength of well-designed treatment optimization studies performed according to rigorous quality standards is greater than or at least equal to that of classical clinical trials. In addition, there was a strong consensus that the results of treatment optimization studies should be taken into account during the decision-making of regulators, payers, and/or clinicians.

Conclusions

Stakeholders involved in drug development consider treatment optimization studies to be valuable tools to address current evidence gaps and support their implementation into the existing research framework.

Breast Tuberculosis in Women: A Systematic Review

Breast tuberculosis (TB) is rarely reported and poorly described. This review aims to update the existing literature on risk factors, clinical presentations, constitutional symptoms, diagnostic procedures, and medical and surgical treatments for breast TB. In all, 1,478 cases of breast TB were collected. Previous history of TB was reported in 19% of cases. The most common clinical appearance of the lesion was breast lump (75%). The most common associated finding was axillary lymphadenitis (33%) followed by sinus or fistula (24%). The most common symptoms were pain and fever, reported in 42% and 28% of cases, respectively. The most used diagnostic method was fine-needle aspiration cytology (32%), followed by biopsy (27%), acid-fast bacteria Ziehl-Neelsen stain (26%), culture (13%), and polymerase chain reaction (2%). These tested positive in 64%, 93%, 27%, 26%, and 58% of cases, respectively. The majority (69%) of patients received a 6-month anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol). Surgery consisted of excision in 39% of cases, drainage in 23%, and mastectomy in 5%. The great majority of patients had a positive outcome. It often mimics breast cancer, which makes it difficult to diagnose. Most patients, when diagnosed in time, respond to antitubercular therapy alone.

An overview of future EU health systems. An insight into governance, primary care, data collection and citizens' participation

Background

Health systems in the European Union (EU) are being questioned over their effectiveness and sustainability. In pursuing both goals, they have to conciliate coexisting, not always aligned, realities.

Methods

This paper originated from a workshop entitled 'Health systems for the future' held at the European Parliament. Experts and decision makers were asked to discuss measures that may increase the effectiveness and sustainability of health systems, namely: (i) increasing citizens' participation; (ii) the importance of primary care in providing integrated services; (iii) improving the governance and (iv) fostering better data collection and information channels to support the decision making process.

Results

In the parliamentary debate, was discussed the concept that, in the near future, health systems' effectiveness and sustainability will very much depend on effective access to integrated services where primary care is pivotal, a clearer shift from care-oriented systems to health promotion and prevention, a profound commitment to good governance, particularly to stakeholders participation, and a systematic reuse of data meant to build health data-driven learning systems.

Conclusions

Many health issues, such as future health systems in the EU, are potentially transformative and hence an intense political issue. It is policy-making leadership that will mostly determine how well EU health systems are prepared to face future challenges.

Impact of Ebola outbreak on reproductive health services in a rural district of Sierra Leone: a prospective observational study

OBJECTIVES

To assess the trends concerning utilisation of maternal and child health (MCH) services before, during and after the Ebola outbreak, quantifying the contribution of a reorganised referral system (RS).

DESIGN

A prospective observational study of MCH services.

SETTING

Pujehun district in Sierra Leone, 77 community health facilities and 1 hospital from 2012 to 2017.

MAIN OUTCOME MEASURES

MCH utililization was evaluated by assessing: (1) institutional deliveries, Cesarean-sections, paediatric and maternity admissions and deaths, and major direct obstetric complications (MDOCs), at hospital level; (2) antenatal care (ANC) 1 and 4, institutional delivery and family planning, at community level. Contribution of a strengthened RS was also measured.

RESULTS

At hospital level, there is a significant difference between trends Ebola versus pre-Ebola for maternal admissions (7, 95% CI 4 to 11, p<0.001), MDOCs (4, 95% CI 1 to 7, p=0.006) and institutional deliveries (4, 95% CI 2 to 6, p=0.001). There is also a negative trend in the transition from Ebola to post-Ebola for maternal admissions (-7, 95% CI -10 to -4, p<0.001), MDOCs (-4, 95% CI -7 to -1, p=0.009) and institutional deliveries (-3, 95% CI -5 to -1, p=0.001). The differences between trends pre-Ebola versus post-Ebola are only significant for paediatric admissions (3, 95% CI 0 to 5, p=0.035). At community level, the difference between trends Ebola versus pre-Ebola and Ebola versus post-Ebola are not significant for any indicators. The differences between trends pre-Ebola versus post-Ebola show a negative difference for institutional deliveries (-7, 95% CI -10 to -4, p<0.001), ANC 1 (-6, 95% CI -10 to -3, p<0.001), ANC 4 (-8, 95% CI -11 to -5, p<0.001) and family planning (-85, 95% CI -119 to -51, p<0.001).

CONCLUSIONS

A stronger health system compared with other districts in Sierra Leone and a strengthened RS enabled health facilities in Pujehun to maintain service provision and uptake during and after the Ebola epidemic.

The association between diabetes and cataract among 42,469 community-dwelling adults in six low- and middle-income countries

BACKGROUND

Cataract is a major cause of visual impairment in people with diabetes, yet a paucity of data is available in low- and middle-income countries (LMICs) on this comorbidity. Thus we assessed the association between diabetes and cataract in 6 LMICs.

METHODS

Cross-sectional, community-based data from the Study on Global Ageing and Adult Health (SAGE) was analyzed (n = 42,469 aged ≥18 years). Five years information on self-reported diagnosis of cataract was collected. Three definitions for cataract were used: (a) Self-reported diagnosis and/or past 12-month symptoms; (b) Solely self-reported diagnosis; and (c) Surgical treatment for cataract in the past five years. Diabetes was based on self-reported diagnosis. Multivariable logistic regression was conducted to assess the associations.

RESULTS

Overall, the prevalence of diabetes was 3.1% (95%CI = 2.7-3.5%) and that of cataract based on the three different definitions was: (a) 13.3% (95%CI = 12.4-14.3%); (b) 4.4% (95%CI = 3.9-4.8%), (c) 1.7% (95%CI = 1.5-2.0%). After adjustment the association was significantly elevated: (a) OR = 2.10 (95%CI = 1.59-2.76); (b) OR = 2.62 (95%CI = 2.00-3.42); (c) OR = 2.80 (95%CI = 1.78-4.40). These associations were particularly pronounced among those aged <50 years.

CONCLUSIONS

A strong association between diabetes and cataract was observed in LMICs. Considering the impact on health and quality of life and the limited treatment options especially for cataract it is mandatory to promote the prevention through bi-directional screening and treatment.

Accelerating the health literacy agenda in Europe

Health literacy can be defined as the knowledge, motivation and competence to access, understand, appraise and apply information to make decisions in terms of healthcare, disease prevention and health promotion. Health literacy is a European public health challenge that has to be taken seriously by policy-makers. It constitutes an emerging field for policy, research and practice. However, recent research has shown that health literacy advancement is still at its infancy in Europe, as reflected in the scarce scientific health literacy literature published by European authors. From a total of 569 articles published until 2011 on this subject, the first author of only 15% of them is from Europe. This article conveys recommendations of different European stakeholders on how to accelerate the health literacy agenda in Europe. A general introduction on the current status of health literacy is provided, followed by two cases applying health literacy in the areas of prevention of communicable diseases and promotion of digital health. The current EU strategies integrating health literacy are listed, followed by examples of challenges threatening the further development of health literacy in Europe. Recommendations as to how European stakeholders involved in research, policy, practice and education can promote health literacy are given. It is vital that the European Commission as well as European Union Member States take the necessary steps to increase health literacy at individual, organizational, community, regional and national levels.

Human health implications of organic food and organic agriculture: a comprehensive review

This review summarises existing evidence on the impact of organic food on human health. It compares organic vs. conventional food production with respect to parameters important to human health and discusses the potential impact of organic management practices with an emphasis on EU conditions. Organic food consumption may reduce the risk of allergic disease and of overweight and obesity, but the evidence is not conclusive due to likely residual confounding, as consumers of organic food tend to have healthier lifestyles overall. However, animal experiments suggest that identically composed feed from organic or conventional production impacts in different ways on growth and development. In organic agriculture, the use of pesticides is restricted, while residues in conventional fruits and vegetables constitute the main source of human pesticide exposures. Epidemiological studies have reported adverse effects of certain pesticides on children's cognitive development at current levels of exposure, but these data have so far not been applied in formal risk assessments of individual pesticides. Differences in the composition between organic and conventional crops are limited, such as a modestly higher content of phenolic compounds in organic fruit and vegetables, and likely also a lower content of cadmium in organic cereal crops. Organic dairy products, and perhaps also meats, have a higher content of omega-3 fatty acids compared to conventional products. However, these differences are likely of marginal nutritional significance. Of greater concern is the prevalent use of antibiotics in conventional animal production as a key driver of antibiotic resistance in society; antibiotic use is less intensive in organic production. Overall, this review emphasises several documented and likely human health benefits associated with organic food production, and application of such production methods is likely to be beneficial within conventional agriculture, e.g., in integrated pest management.

Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study

Background

Ethiopia has high maternal mortality ratio and poor access to maternal health services. Attendance of at least four antenatal care (ANC) visits and delivery by a skilled birth attendant (SBA) are important in preventing maternal deaths. Understanding the reasons behind the poor use of these services is important in designing strategies to address the problem. This study aimed to determine the coverage of at least four ANC visits and delivery by a SBA and to identify determinants of utilisation of these services in three districts in South West Shoa Zone, Ethiopia.

Methods

A cross-sectional survey of 500 women aged 15–49 years with a delivery in two years prior to the survey was conducted in Wolisso, Wonchi and Goro districts in February 2013. Data were collected using an interviewer administered questionnaire. Logistic regression models were used to explore determinants of ANC attendance and SBA at delivery.

Results

Coverage of at least four ANC visits and SBA at delivery were 45.5 and 28.6 %, respectively. Most institutional deliveries (69 %) occurred at the single hospital that serves the study districts. Attendance of at least four ANC visits was positively associated with wealth status, knowledge of the recommended number of ANC visits, and attitude towards maternal health care, but was negatively associated with woman’s age. SBA at delivery was negatively associated with parity and time to the health facility, but was positively associated with urban residence, wealth, knowledge of the recommended number of ANC visits, perceived good quality of maternal health services, experience of a pregnancy/delivery related problem, involvement of the partner/family in decision making on delivery place, and birth preparedness.

Conclusions

Raising awareness about the minimum recommended number of ANC visits, tackling geographical inaccessibility, improving the quality of care, encouraging pregnant women to have a birth and complication readiness plan and community mobilisation targeting women, husbands, and families for their involvement in maternal health care have the potential to increase use of maternal health services in this setting. Furthermore, supporting health centres to increase uptake of institutional delivery services may rapidly increase coverage of delivery by SBA and reduce inequity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0067-y) contains supplementary material, which is available to authorized users.

Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey

Background

Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation’s lowest scores on key development and health indicators and presents a substantial challenge to Uganda’s stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided.

Methods

A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated.

Results

There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section.

Conclusions

To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.

Quality of life in a cohort of high-dose benzodiazepine dependent patients

BACKGROUND

Benzodiazepines (BZD) are among the most widely prescribed drugs in developed countries. Since BZD can produce tolerance and dependence even in a short time, their use is recommended for a very limited time. However, these recommendations have been largely disregarded. The chronic use of BZD causes a number of serious side effects, i.e., cognitive impairment, falls, traffic accidents, dependence and tolerance. The aim of the present study was to evaluate quality of life (QoL) in a cohort of 62 consecutive high-dose BZD-dependent patients seeking a BZD detoxification.

METHODS

Patients seeking BZD detoxification were evaluated using the General Health Questionnaire (GHQ-12) and the short form-36 questionnaire (SF-36).

RESULTS

Patients showed a significant reduction of QoL as measured by either SF-36 or GHQ-12. In particular, the greater impairment was observed in the items exploring physical and emotional status. Physical functioning was the item more influenced by the length of BZD abuse. Female patients showed a greater reduction of QoL compared to male, at least in some of the explored items. Social functioning scores were greatly reduced.

CONCLUSIONS

The present study shows for the first time that high-doses BZD dependent patients have a reduced QoL and a reduced social functioning, along with high levels of psychological distress.

A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming

BACKGROUND

Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda.

METHODS

Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified.

RESULTS

The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery.

CONCLUSION

A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

Factors associated with patient and health care system delay in diagnosis for tuberculosis in the province of Luanda, Angola

Background

Tuberculosis (TB) is still a great challenge to public health in sub-Saharan Africa. Most transmissions occur between the onset of coughing and initiation of treatment. Delay in diagnosis is significant to disease prognosis, thus early diagnosis and prompt effective therapy represent the key elements in controlling the disease. The objective of this study was to investigate the factors influencing the patient delay and the health system delay in TB diagnosis in Angola.

Methods

On a cross-sectional study, 385 TB patients who visited 21 DOTS clinics in Luanda were included consecutively. The time from the onset of symptoms to the first consultation of health providers (patients’ delay) and the time from the first consultation to the date of diagnosis (health system’s delay) were analysed. Bivariate and logistics regression were applied to analyse the risk factors of delays.

Results

The median total time elapsed from the onset of symptoms to diagnosis was 45 days (interquartile range [IQR]: 21–97 days). The median patient delay was 30 days (IQR: 14–60 days), and the median health care system delay was 7 days (IQR: 5–15 days). Primary education (AOR = 1.75; CI [95%] 1.06–2.88; p <0.029) and the health centre of the first contact differing from the DOTS centre (AOR = 1.66; CI [95%] 1.01–2.75; p <0.046) were independent risk factors for patient delay >4 weeks. Living in a suburban area (AOR = 2,32; CI [95%] 1.21–4.46; p = 0.011), having a waiting time in the centre >1 hour (AOR = 4.37; CI [95%] 1.72–11.14; p = 0.002) and the health centre of the first contact differening from the DOTS centre (AOR = 5.68; CI [95%] 2.72–11,83; p < 0,00001) were factors influencing the system delay.

Conclusions

The results indicate that the delay is principally due to the time elapsed between the onset of symptoms and the first consultation. More efforts should be placed in ensuring the availability of essential resources and skills in all healthcare facilities other than the DOTS centres, especially those located in suburban areas.

High dose benzodiazepine dependence: description of 29 patients treated with flumazenil infusion and stabilised with clonazepam

The withdrawal syndrome from benzodiazepine (BZD) can be severe and in some cases may impede cessation of the use of the drug. We present here a case series of benzodiazepine detoxification by flumazenil infusion, stabilised with clonazepam. Patients were treated with flumazenil 1.35 mg/day for a median of 7 days. Self-reported physical withdrawal symptoms were recorded daily. In addition to flumazenil, antidepressants were given before treatment commenced and clonazepam was administered nightly with both being continued after discharge. Twenty-nine patients were treated. No patients dropped out from the treatment programme. Nine patients (31%) required a temporary reduction/cessation of the infusion. The linear trend in the reduction of the daily withdrawal scores in the overall study population was significant. The linear trends were also significant in the group of patients for whom a temporary reduction/suspension of the flumazenil was required. Six months after treatment, 15 patients (53%) were abstinent from clonazepam and other BZDs. For five (21%) the BZD dependence were reinstated. More than two-thirds of the subjects tolerated the procedure well and about half had a good long term response. Slow flumazenil infusion appears to merit consideration as a possible future treatment. Suggestions for future research are examined.

Lormetazepam addiction: data analysis from an Italian medical unit for addiction

Background

The purpose of this study was to determine, in the context of a hospital addiction unit, which benzodiazepines were abused and to look for correlations with the characteristics of detoxified patients.

Methods

A retrospective study was carried out using the database of hospital admissions to the addiction unit for detoxification from 2003 to 2010.

Results

Of 879 admissions to the addiction unit during the seven-year period, 281 were for benzodiazepines. The percentage of patients addicted only to benzodiazepines was higher among females than males. Benzodiazepine consumption had started as a drug addiction behavior in only 10% of cases. The main sources of prescription identified were general practitioners (52% of cases) or compliant pharmacists (25%). Overall, 15 different benzodiazepines were abused, with lormetazepam being the most commonly used (by 123 patients, 43.8% of the total).

Conclusion

Our data show that, outside the population of multidrug addicts, there is an underestimated group of chronic benzodiazepine consumers who are often not referred to medical institutions for treatment. Even in the group of patients addicted to one substance only, we observed an abnormal number of requests for detoxification from lormetazepam, which appears to be more “popular” than other benzodiazepines. This drug should be prescribed according to stricter criteria and submitted to closer control.

Tobacco addiction and smoking status in heroin addicts under methadone vs. buprenorphine therapy

Aims of the present investigation were: (i) to assess the prevalence of current smokers and relative smoking status among a large number of heroin addicts attending opioid-substitution therapy prevalence; (ii) to evaluate the relationship between the type (methadone, buprenorphine) and dosage of opioid substitution therapy and nicotine dependence. Three hundred and five (305) heroin addicts under opioid-substitution therapy were recruited at five Addiction Units. All participants completed a questionnaire assessing sociodemographic information, type and dose of opioid-substitution therapy, smoking history and status, Fagerström Test for Nicotine Dependence (FTND), and the Zung Self-Rating Depression scale (SDS). 298 subjects, out of 305 (97.2%) were smokers, with an average of 20.5 cigarette/day and a median FTND of 6. Our data confirmed the high prevalence of smokers among heroin addicts, the highest described in the literature to date among heroin addicts under substitution therapies, without any significant difference between methadone vs. buprenorphine therapy groups. There was no correlation between dose of methadone or buprenorphine and average number of cigarettes/day. Patients in substance abuse treatment very frequently smoke cigarettes and often die of tobacco-related diseases. Substance abuse treatment programs too often ignore tobacco use. We hope that these findings will help to incorporate smoking cessation in substance abuse treatments.

Focal nonconvulsive seizures during detoxification for benzodiazepine abuse

Chronic benzodiazepine (BDZ) abuse is currently treated with detoxification using a low-dose flumazenil infusion, a relatively recently developed and promising procedure. Given the possibility reported in the literature of the occurrence of generalized seizures during therapeutic BDZ detoxification, we usually administer preventive antiepileptic drug (AED) therapy. We describe two patients with no previous history of seizures or evidence of intracerebral lesions who, during detoxification for benzodiazepine abuse, developed repetitive focal nonconvulsive seizures instead of generalized seizures, even with appropriate doses of preventive AED therapy. There are no previous reported cases of focal nonconvulsive seizures occurring during this procedure or, more generally, during abrupt BDZ discontinuation. The cases we describe suggest that during detoxification for BDZ abuse, not only generalized, but also focal nonconvulsive seizures may occur. In this context, the focal seizures probably result from a diffuse decrease in the seizure threshold (caused by a generalized excitatory rebound), which may trigger focal seizures arising from cortical regions with higher intrinsic epileptogenicity. Detoxification for benzodiazepine abuse, even if performed with adequate-dosage AED treatment, may not be as safe a procedure as previously considered, because not only convulsive, but also nonconvulsive seizures may occur and go unnoticed. It is therefore strongly advisable to perform this detoxification under close medical supervision and to maintain a low threshold for EEG monitoring in the event of sudden onset of behavioral changes.

The selection of experts evaluating health projects for the EU Sixth Framework Program

Aim

The Framework Programmes for Research and Technological Development (FP) are the European Union’s funding programmes for research in Europe. The study analyses the features of external experts involved in evaluating the research proposals in FP6 (years 2003–2006) in the area of Life Sciences.

Subjects and methods

Experts were analysed with respect to nationality, gender, organisational affiliation and rotation. The correlations between the number of experts by nationality and scientific research indicators were also explored.

Result

Experts from 70 countries participated, with 70% coming from 10 countries. The gender composition was relatively stable, with approximately 30% of female experts. The majority of experts came from higher education establishments (51%) and 12% from industry. About 40% of experts participated in the evaluation process two or more times. The number of experts by nationality was linearly correlated with gross national income (r = 0.95, p < 0.0001), population (r = 0.91, p < 0.0001), and number of research publications in health sciences (r = 0.93, p < 0.0001). However, using multiple linear regression analysis, only gross national income had partial regression coefficients significantly different from zero (p = 0.017). The observed value of experts for Italy (312) and Belgium (155) were higher than predicted by this regression model (231 and 71 respectively).

Conclusion

The expert panels involved were balanced with respect to nationalities, whereas the gender distribution was lower than the target. There was a satisfactory degree of rotation of experts between evaluation rounds. The percentage of experts from industry was lower than expected.

Ambulance service within a comprehensive intervention for reproductive health in remote settings: a cost-effective intervention

OBJECTIVE

To assess the cost-effectiveness of an ambulance service within a comprehensive hospital/community-based program aimed at improving access and quality of reproductive health in poor-resources settings.

METHODS

Obstetrical cases referred to the hospital with the ambulance during a 3-month period were prospectively recorded. Clinical indications were used to determine the effectiveness of the referral; the direct costs of the service were calculated. Overall effectiveness was then measured against WHO thresholds.

RESULTS

Ninety-two obstetrical referrals were recorded. Eleven (12%) were considered effective, corresponding to 611.7 years saved. Cost per year saved was 15.82 US dollars which about half of WHO's 30 US dollar benchmark defining very attractive interventions. Sensitivity analyses on the costs of the ambulance and the rate of effective referrals emphasized the robustness of the result.

CONCLUSIONS

The cost-effectiveness profile of an ambulance service within a series of interventions aimed at improving reproductive health in remote settings is very attractive.

Toxoplasmosis in Kosovo pregnant women

This study presents the initial results of a collaborative project aimed at the evaluation of Toxoplasma seroprevalence in a population of Kosovar pregnant women. The serum samples of 334 pregnant women were tested to detect IgG, IgM, IgG avidity for toxoplasmosis. Data regarding age, occupation, area of origin and education were also obtained for the pregnant women examined; 97/334 (29.4%) resulted positive for IgG antibodies, four of whom (4.1%) were also positive for IgM, (1.2% of the total population examined). All four IgM-positive pregnant women also demonstrated low avidity tests. The rate of IgG seroprevalence found in our study was lower than that observed in various European countries, especially those of western Europe. Conversely, the percentage of recent infections was higher than expected. The higher rate of infections could be the result of a recent toxoplasmosis epidemic in Kosovo, most likely due to the altered hygienic conditions caused by the forced transfer of the ethnic-Albanian population from an area of low (Serbia) to high (Kosovo) toxoplasmosis prevalence.

Prevalence of antibodies to phleboviruses and flaviviruses in Peja, Kosovo

In order to investigate the current and past activity of phlebovirus and flavivirus in Kosovo, a seroprevalence study among 200 blood donors was performed. Positive results were obtained for the phleboviruses TOSV and SFNV, and for a flavivirus of the Japanese Encephalitis group. No positive results for TBEV were observed.

Hepatitis A Virus among Drug Users and the Role of Vaccination: A Review

In countries with advanced economies better health and hygiene conditions, along with the introduction, in some cases, of global vaccination, have relegated most viral hepatitis to marginal social groups and, in particular, drug users (DUs). The availability of safe and effective vaccines for hepatitis A virus (HAV) and B (HBV) may play a major role in combating this phenomenon. Despite the availability of a safe and effective vaccine for over a decade and the recommendations of international health organizations, vaccinations against HAV among DUs are not as widely known and available as are HBV vaccinations. The purpose of this review article is to present the most significant data in the literature on the prevalence of HAV among DUs and the role of targeted vaccination. To our knowledge, the present article is the first to solely deal with vaccination against HAV in DUs. Immunization after the administration of anti-HAV vaccine has been demonstrated in DUs even if they have responded significantly less than either the general population or carriers of chronic liver disease. All the vaccines were well tolerated and adherence to the vaccine schedule was good. Further studies are needed to optimize the timing and doses of vaccine to be administered to DUs, especially to assess adherence and antibody persistence. Vaccination campaigns are feasible among DUs and have proven to be highly cost-effective.

Buprenorphine in maintenance treatment: experience among Italian physicians in drug addiction centers

The aim of this study was to assess the attitudes of Italian physicians regarding buprenorphine and its clinical use approximately 6 years after the medication was introduced into clinical practice. The sample consisted of 305 randomly selected physicians, working in public centers of drug addiction. In Italy buprenorphine seems a valid tool in the field of drug addiction treatment, although it is far from replacing methadone even though it seems to guarantee better compliance. Interviewees follow clinical experience more than international guidelines, with pharmaceutical company representatives as the most cited source for information about the medication. The data also suggests a need for the development of formal guidelines for treatment with buprenorphine in Italy.

Progressive decrease of hepatitis B in a cohort of drug users followed over a period of 15 years: The impact of anti-HBV vaccination

In the Western world, the population at the highest risk of HBV infection is probably that of illicit drug users (DUs). Since 1985, 1 Public Health Centre for Drug Users (PHCDU), in north-eastern Italy, has been asking all heroin DUs, whether in treatment or not, to undergo screening for HIV, HBV and, since 1989, for HCV infection. Since 1988 the Centre has proposed HBV vaccination to all patients who were negative for all HBV markers. From 1985 to 2001 895 heroin DUs were screened, 726 males and 169 females. 442 (49.4%) were negative to HBV markers at the first control and 72.4% received at least 1 dose of the vaccine. 320 DUs were vaccinated and a total of 995 doses of recombinant vaccine were administered. The anti-HBc antibody appeared in 2 vaccinated patients out of 258 DUs undergoing controls, while 13 seroconversions for anti-HBc occurred in 45 DUs who had refused to be vaccinated. On the basis of these results, HBV vaccination of DUs can be strongly recommended. Vaccination showed a good adherence in a population difficult to treat and can have a leading role in reducing HBV infection in DUs and their contacts.

Seroprevalence of HIV, HSV-2, and Treponema pallidum in the Kosovarian population

The objective of this study was to evaluate the seroprevalence of infection with HIV, herpes simplex virus type 2 (HSV-2), and Treponema pallidum (TP) in a Kosovarian population. A cross-sectional study was performed in Peja, Kosovo, from January to March 2005, among 1285 persons recruited at the Peja Hospital. The seroprevalence of HIV, HSV-2, and TP was evaluated, and the viral correlates for each infection were analysed. No HIV-positive cases were found. The seroprevalence of HSV-2 was 20.2%. The factors significantly associated with HSV-2 infection at the multivariate analysis were: female gender (adjusted OR, 1.73; 95% CI 1.24-2.41) and being married (adjusted OR, 1.46; 95% CI 1.06-2.01). Three persons (0.2%) had a positive serology for TP. The only risk factor associated with TP infection was age = 50 y. Our results show a low seroprevalence of HIV infection and TP, and a high seroprevalence of HSV-2 in Kosovo. These findings suggest the need for appropriate surveillance systems, prevention programmes, and information aimed at controlling the spread of HIV and other sexually transmitted infections in this area. Moreover, the circulation of infections acquired through sexual contact may facilitate an increase in the sexually transmitted HIV epidemic in the near future.

Anabolic steroids: dependence and complications of chronic use

Anabolic steroids are widely used for doping, in professional and domestic sports. The mechanism of action is not completely understood. It may differ somewhat depending on the specific molecule due to structural differences that influence the specificity of binding with steroid receptors. When used by athletes in training, they can improve performance to levels that cannot be attained by almost any combination of sophisticated nonchemical support by modern sport science. The severity of the undesired effects of anabolic steroids depends on a variety of factors, from the type and combination of them, the dose and duration of administration, as well as the gender of the person taking the drug. Younger individuals and women show greater effects caused by anabolic steroids in terms of performance, but are also at greater risk of side effects. This paper presents a review of the literature concerning the major adverse effects of anabolic steroids, focusing the attention on possible situations of addiction from this category of drugs.

Bloodborne viral hepatitis infections among drug users: the role of vaccination

Drug use is a prevalent world-wide phenomenon and hepatitis virus infections are traditionally a major health problem among drug users (DUs). HBV and HCV, and to a lesser extent HAV, are easily transmitted through exposure to infected blood and body fluids. Viral hepatitis is not inevitable for DUs. Licensed vaccines are available for hepatitis A and hepatitis B. The purpose of this overview is to show some epidemiological data about HBV and the other blood-borne viral hepatitis among DUs and to summarize and discuss use of hepatitis vaccinations in this population. Successful vaccination campaigns among DUs are feasible and well described. We try to focus on the most significant results achieved in successful vaccination programs as reported in scientific literature. Vaccination campaigns among DUs represent a highly effective form of health education and they are cost-saving.

Venlafaxine dependence in a patient with a history of alcohol and amineptine misuse

BACKGROUND

Venlafaxine is an inhibitor of neuronal serotonin and noradrenaline re-uptake and a weak inhibitor of dopamine re-uptake. There was no indication of problems of abuse/dependence during the clinical trials.

CASE DESCRIPTION

A 53-year-old client with a history of alcohol and amineptine misuse and a long history of recurrent depression, for which he was prescribed venlafaxine tablets. Over time, he increased the dosage to 50 tablets daily (3750 mg). Large venlafaxine dosages produced amphetamine-like effects, due possibly to the related increase in dopamine turnover. Once hospitalized for detoxification, the patient had a symptomatology which was consistent with a serotonergic discontinuation syndrome.

CONCLUSIONS

Physicians should be aware that patients with a history of drug and alcohol abuse might develop venlafaxine dependence.

Prevalence and risk factors for viral hepatitis in the Kosovarian population: implications for health policy

The prevalence of hepatitis infection among the Kosovarian population is largely unknown. The aim of the study was to evaluate the prevalence and risk factors of hepatitis A, B, C, and D (HAV, HBV, HCV, HDV) infection among the general population and in a group of health care workers in the Kosovo region. Overall, 1,287 participants were recruited, 460 males (36%) and 827 females (64%). Health care workers accounted for 253 individuals (20%), 301 were blood donor candidates (23%), 334 were pregnant women (26%), and 399 (31%) were subjects who had been examined in two clinics for routine laboratory testing. The prevalence of total anti-HAV was 88.6% (95% CI: 86.69-90.25). Prevalence of anti-HAV among children up to 10 years was 40.5% (95% CI: 29.6-53.15), reaching 70% (95% CI: 62.25-77.10) in the 11-20 age group. Age, living in rural areas and unemployment were factors associated with higher risk of HAV infection. HBsAg was detected in 2.4% (95% CI: 1.57-3.38%) of the study sample, with a significant age trend (P-value:0.0110). Positivity for total anti-HBc was detected in 18.4% (95% CI = 16.27-20.59) of the subjects. Ninety-three subjects (7.2%) were positive for anti-HBs alone. An association between age, HSV-2 positivity, working nurses and HBV infection has been observed. One patient was HDV positive. The prevalence for HCV was 0.5% (95% CI: 0.22-1.12%). HAV infection seems to be high-intermediate, while HBV shows an intermediate endemicity. It is necessary to highlight the importance of an immunization strategy against HAV and HBV in reducing the incidence of the infection. The prevalence for HCV was very low.

Erectile dysfunction in male heroin users, receiving methadone and buprenorphine maintenance treatment

Erectile dysfunction (ED) is common among people in treatment for heroin addiction. The purpose of the study was to examine the frequency of ED among methadone and buprenorphine maintenance therapy patients, and to identify factors associated with ED. Patients - recruited from 7 centres in Italy - underwent: (i) a structured interview on socio-demographic characteristics, drug use and sexual behaviour; (ii) IIEF-15 test, a test of sexual function; (iii) Zung test for depression. The study included 201 males: 42% were on methadone maintenance, 58% were on buprenorphine. Overall, 58% reported no ED, 24% reported mild to moderate ED, and 18% severe ED. In univariate analysis buprenorphine patients had less ED than methadone patients (p=0.0135). Subjects living with a partner had less ED than others (p=0.0018). More depressed subjects had more ED (p<0.001). Heterosexual patients reported less ED than homo/bisexual patients (p=0.0427), and partner's use of heroin was associated with more ED (p=0.0078). The significant univariate predictors were entered into a cumulative logit model. Living with a sexual partner was associated with a lower likelihood of ED, while depression, having a sexual partner with a history of drug use and not having a steady partner were associated with a greater likelihood of ED. The significant association between treatment and ED which appeared in univariate analysis (with buprenorphine patients reporting less ED than methadone patients) was not confirmed by the multivariate analysis. Both psychological and social factors were associated with ED which is an important problem for many males in methadone and buprenorphine treatment.

Association between depressive mood and cigarette smoking in a large Italian sample of smokers intending to quit: implications for treatment

OBJECTIVE

The aim of the study is to assess the prevalence and degree of depression at baseline of a large cohort of smokers intending to quit.

METHODS

A cross-sectional investigation was carried out on a population of 757 smokers attending the Medical Service for Addictive Disorders, at Verona University Hospital. The degree of nicotine addiction was measured by the Fagerstrom Test of Nicotine Dependence (FTND) and current mood tested by the Self-rating Depression Scale (SDS), a commonly used and well validated instrument to assess depressive mood.

RESULTS

Two hundred and twenty-two subjects (30.3%) were depressed at baseline (SDS test score > or = 50). Bivariate analysis, using the SDs score dichotomised at the cut-off of 50 as dependent variable, shows that female gender (p=0.01) and widowhood (p<0.001) were correlated to depression. Logistic regression analysis confirms the correlation between depression and female gender (OR=2.03, IC 95%=1.42-2.88, p<0.001) and between depression and widowhood, with the greatest risk of depression among widows and widowers (OR=3.22, IC 95%=1.01-10.27, p<0.048).

CONCLUSIONS

The study showed a high degree of pre-treatment depression in smokers intending to quit. Although the association between depression and nicotine dependence has been consistently reported many times, and it is well known that depressed subjects find it more difficult to quit, most guidelines seem not to consider this connection. These findings suggest the need for baseline assessment of depression by screening all smokers seeking assistance in quitting, a priority health objective because smoking is the number one avoidable killer in developed countries.

Patients in long-term maintenance therapy for drug use in Italy: analysis of some parameters of social integration and serological status for infectious diseases in a cohort of 1091 patients

BACKGROUND

Heroin addiction often severely disrupts normal social functioning. The aims of this multi-centre study of heroin users in long-term replacement treatment were: i) to provide information on aspects of social condition such as employment, educational background, living status, partner status and any history of drug addiction for partners, comparing these data with that of the general population; ii) to assess the prevalence of hepatitis, syphilis and HIV, because serological status could be a reflection of the social conditions of patients undergoing replacement treatment for drug addiction; iii) to analyse possible relationships between social conditions and serological status.

METHODS

A cross-sectional study was carried out in sixteen National Health Service Drug Addiction Units in northern Italy. The data were collected from February 1, 2002 to August 31, 2002. Recruitment eligibility was: maintenance treatment with methadone or buprenorphine, treatment for the previous six months, and at least 18 years of age. In the centres involved in the study no specific criteria or regulations were established concerning the duration of replacement therapy. Participants underwent a face-to-face interview.

RESULTS

The conditions of 1091 drug treatment patients were evaluated. The mean duration of drug use was 14.5 years. Duration was shorter in females, in subjects with a higher educational background, and in stable relationships. Most (68%) had completed middle school (11-14 years of age). Seventy-nine percent were employed and 16% were unemployed. Fifty percent lived with their parents, 34% with a partner and 14% alone. Males lived more frequently with their parents (55%), and females more frequently with a partner (60%). Sixty-seven percent of male patients with a stable relationship had a partner who had never used heroin. HCV prevalence was 72%, HBV antibodies were detected in 42% of patients, while 30% had been vaccinated; 12.5% of subjects were HIV positive and 1.5% were positive for TPHA.

CONCLUSION

A significant percentage of heroin users in treatment for opiate addiction in the cohort study have characteristics which indicate reasonable integration within broader society. We posit that the combination of effective treatment and a setting of economic prosperity may enhance the social integration of patients with a history of heroin use.

Hepatitis vaccination among drug users

Hepatitis virus infections are traditionally a major health problem among drug users (DUs). Several factors may favor the rapid spread of hepatitis infection in this category of patients. HBV and HCV are easily transmitted through exposure to infected blood and body fluids. DUs often prepare and use drug solutions together. Many in the DU community are infected and this provides multiple opportunities for transmission to others. Many of these patients with chronic hepatitis virus infection are not aware of their infections and this facilitates the spread of the diseases. Viral hepatitis is not inevitable for DUs. Although multiple factors have prevented the development of vaccines for hepatitis C, both hepatitis A and hepatitis B can be prevented by immunization. The purpose of this overview is to summarize and discuss the hepatitis vaccination in this population.