Is the universal population Hepatitis C virus screening a cost-effective strategy? A systematic review of the economic evidence

Background

Efficient strategies are needed in order to achieve the objective of the WHO of eradicating Hepatitis C virus (HCV). Hepatitis C infection can be eliminated by a combination of direct acting antiviral (DAA). The problem is that many individuals remain undiagnosed. The objective is to conduct a systematic review of the evidence on economic evaluations that analyze the screening of HCV followed by treatment with DAAs.

Methods

Eleven databases were performed in a 2015-2018-systematic review. Inclusion criteria were economic evaluations that included incremental cost-effectiveness ratio (ICER) in terms of cost per life year gained or quality-adjusted life year.

Results

A total of 843 references were screened. Sixteen papers/posters meet the inclusion criteria. Ten of them included a general population screening. Other populations included were baby-boomer, people who inject drugs, prisoners or immigrants. Comparator was “standard of care”, other high-risk populations or no-screening. Most of the studies are based on Markov model simulations and they mostly adopted a healthcare payer´s perspective. ICER for general population screening plus treatment versus high-risk populations or versus routinely performed screening showed to be below the accepted willingness to pay thresholds in most studies and therefore screening plus DAAs strategy is highly cost-effective.

Conclusion

This systematic review shows that screening programmes followed by DAAs treatment is cost-effective not only for high risk population but for general population too. Because today HCV can be easily cured and its long-term consequences avoided, a universal HCV screening plus DAAs therapies should be the recommended strategy to achieve the WHO objectives for HCV eradication by 2030.

Estudio básico del comportamiento ambiental en la caldera del volcán inactivo Pululahua utilizando un sistema de adquisición y procesamiento de datos basado en UAV

En este trabajo se presenta un análisis básico del comportamiento ambiental en la caldera volcánica habitada del volcán Pululahua. El análisis ha sido desarrollado mediante el uso de un sistema de adquisición y procesamiento de datos en tiempo real basado en un UAV (Unmanned Aerial Vehicle, Vehículo Aéreo No Tripulado)  para vuelos a baja altura. El sistema es un prototipo de dos etapas desarrollado en base a software y hardware libre. La primera etapa (aire) del sistema es instalada en el Dron y permite la adquisición de información ambiental (temperatura, humedad y presión) con su respectiva georreferenciación, esta información es transmitida utilizando un enlace inalámbrico de 2,4 GHz y es procesada en la segunda etapa (tierra), para obtener isomapas de las variables mencionadas anteriormente, para altitudes de hasta 120 m desde la posición de despegue. La información obtenida en la caldera muestra, como es de esperarse, que tanto la temperatura como la presión, disminuyen con el incremento de la altura, contrariamente a la humedad que se eleva a la par que la altitud. A partir de los datos recopilados se puede ver que la temperatura y la humedad varían ampliamente durante los primeros 20 m (por encima del lugar de despegue) pero después de los 50 m se vuelven estables. Algo bastante llamativo también es la variación de la presión (aproximadamente de 6 a 10 hPa) en una misma altura pero en diferentes posiciones.

Soybean-Macrophomina phaseolina-Specific Interactions and Identification of a Novel Source of Resistance

Charcoal rot, caused by the fungus Macrophomina phaseolina, is an economically important disease of soybean (Glycine max) worldwide. Objectives of the present research were to (i) study the genetic and pathogenic diversity in a collection of M. phaseolina isolates from Argentina and Paraguay and (ii) develop an improved in vitro phenotyping method to evaluate disease response of soybean genotypes to M. phaseolina isolates. Cluster analysis showed no clear association among simple sequence repeat profiles, year of collection, pathogenicity, and geographical origin of the isolates from Argentina and Paraguay. Subsequently, the response of four soybean genotypes against seven M. phaseolina isolates was evaluated in the field and the results were confirmed using the in vitro assay developed. This assay, which is based on root disease development on soybean seedlings, allowed the detection of a differential level of aggressiveness among the isolates on four soybean genotypes. The results suggest the existence of specific interactions among soybean genotypes and M. phaseolina isolates. In addition, cultivar Munasqa RR showed a superior response against M. phaseolina compared with DT 97-4290 (moderately resistant), thus becoming a novel source of resistance to charcoal rot.

Effect of Akt activation and experimental pharmacological inhibition on responses to neoadjuvant chemoradiotherapy in rectal cancer

BACKGROUND

Neoadjuvant chemoradiotherapy (CRT) is one of the preferred initial treatment strategies for locally advanced rectal cancer. Responses are variable, and most patients still require surgery. The aim of this study was to identify molecular mechanisms determining poor response to CRT.

METHODS

Global gene expression and pathway enrichment were assessed in pretreatment biopsies from patients with non-metastatic cT2-4 N0-2 rectal cancer within 7 cm of the anal verge. Downstream Akt activation was assessed in an independent set of pretreatment biopsies and in colorectal cancer cell lines using immunohistochemistry and western blot respectively. The radiosensitizing effects of the Akt inhibitor MK2206 were assessed using clonogenic assays and xenografts in immunodeficient mice.

RESULTS

A total of 350 differentially expressed genes were identified, of which 123 were upregulated and 199 downregulated in tumours from poor responders. Mitochondrial oxidative phosphorylation (P < 0·001) and phosphatidylinositol signalling pathways (P < 0·050) were identified as significantly enriched pathways among the set of differentially expressed genes. Deregulation of both pathways is known to result in Akt activation, and high immunoexpression of phosphorylated Akt S473 was observed among patients with a poor histological response (tumour regression grade 0-2) to CRT (75 per cent versus 48 per cent in those with a good or complete response; P = 0·016). Akt activation was also confirmed in the radioresistant cell line SW480, and a 50 per cent improvement in sensitivity to CRT was observed in vitro and in vivo when SW480 cells were exposed to the Akt inhibitor MK2206 in combination with radiation and 5-fluorouracil.

CONCLUSION

Akt activation is a key event in the response to CRT. Pharmacological inhibition of Akt activation may enhance the effects of CRT. Surgical relevance Organ preservation is an attractive alternative in rectal cancer management following neoadjuvant chemoradiotherapy (CRT) to avoid the morbidity of radical surgery. Molecular steps associated with tumour response to CRT may provide a useful tool for the identification of patients who are candidates for no immediate surgery. In this study, tumours resistant to CRT were more likely to have activation of specific genetic pathways that result in phosphorylated Akt (pAkt) activation. Pretreatment biopsy tissues with high immunoexpression of pAkt were more likely to exhibit a poor histological response to CRT. In addition, the introduction of a pAkt inhibitor to cancer cell lines in vitro and in vivo led to a significant improvement in sensitivity to CRT. Identification of pAkt-activated tumours may thus allow the identification of poor responders to CRT. In addition, the concomitant use of pAkt inhibitors to increase sensitivity to CRT in patients with rectal cancer may constitute an interesting strategy for increasing the chance of a complete response to treatment and organ preservation.

Pain in clinical oncology: patient satisfaction with management of cancer pain

BACKGROUND

Despite effective analgesic therapy, inadequate pain control is frequently perceived by patients and caregivers.

AIMS

To assess satisfaction with management of pain in cancer patients.

METHODS

Between January and May 2007, a cross-sectional multicentre study was conducted in 64 Medical Oncology Departments throughout Spain. A total of 525 outpatients with oncological diseases completed a questionnaire with demographic data, characteristics and intensity of pain, and perceptions and attitudes towards pain management at the time of a routine clinical visit. Physicians also completed a questionnaire with tumour-related and treatment-related data. Cluster analysis was used to classify patients into three groups (satisfied, neither satisfied nor dissatisfied or neutral, dissatisfied) according to pain intensity and satisfaction with treatment.

RESULTS

Patients satisfied with their analgesic treatment (33%) had lower pain intensities and, when regularly asked about their pain, considered their physicians to be more involved in their treatment. Neither satisfied nor dissatisfied patients (neutral) (44%) had higher mean pain intensities. Two-thirds of them achieved marked relief of their pain and also thought that physicians were aware of their situation. Dissatisfied patients (23%) had moderate to severe pain intensities, and said that they were asked less frequently about their pain, and thought that their physicians were less involved in their analgesic treatment.

CONCLUSION

Physician-patient communication and information provided to patients are essential aspects of patient perceptions and attitudes towards control of cancer-related pain. Pain is seen as a condition that may be controlled but affects the capacity to lead a normal life.

Penicillin-susceptible and erythromycin-resistant Streptococcus pneumoniae in children with acute mastoiditis

Resistance to erythromycin is usually associated with resistance to penicillin in Streptococcus pneumoniae isolates. Over the last few years, however, an increase has been detected in the number of Streptococcus pneumoniae isolates obtained from children with acute otitis media complicated by acute mastoiditis. These isolates are characterized by a penicillin-susceptible and erythromycin-resistant antibiotic profile. This observation prompted a review of the microbiology database and analysis of all Streptococcus pneumoniae isolates with this peculiar antibiotic profile at a university hospital in Madrid, Spain.

Frogeye Leaf Spot of Soybean Caused by Cercospora sojina in Northwestern Argentina

Frogeye leaf spot of soybean (Glycine max (L.) Merr.), caused by Cercospora sojina Hara, was first detected during the 1997-98 growing season at low incidence and severity (<1% of the leaf diseased) levels in the provinces of Tucumán, Salta, Jujuy, Catamarca, and Santiago del Estero in northwestern Argentina. During the 1998-1999 growing season, disease incidence increased and disease severity grew to 10% of the leaf surface diseased on highly susceptible cultivars in a few locations. An outbreak of frogeye leaf spot occurred throughout northwestern Argentina during the 1999-2000 growing season. Frogeye leaf spot was severe on susceptible cultivars in the provinces of Salta, Santiago del Estero and Catamarca with the greatest intensity in the northeastern part of the Province of Tucumán. Symptoms on leaves were circular lesions that ranged in size from 1 to 5 mm, were reddish-brown to gray or tan, and were bordered by a narrow, reddish-brown to purple margin. Conidiophores and conidia of C. sojina developed on the abaxial leaf surface (1,2). Severely diseased leaves were desiccated and dropped during the R6 stage of growth. Lesions also developed on stems, pods, and seeds. Field surveys indicated that this disease reduced the yields of the highly susceptible cultivars Anta 82 RR, Coker 6738, and A 6445 RG by 48, 34, and 25%, respectively. C. sojina was cultured from diseased tissue on PDA acidified with 0.2% lactic acid and maintained on V-8 juice agar amended with streptomycin sulfate (100 mg/l). Conidia were elongated, dark, 38 to 62 × 5 to 9 μm, with 2 to 6 septa, and borne on dark conidiophores with 1 to 4 septa. Pathogenicity tests were conducted on seedlings of the susceptible cultivars A 6445 RG and Coker 6738 and on the resistant cultivars A 8000 RG and Shulka. Seedlings were inoculated at the V3 growth stage by spraying the leaves with a conidial suspension (4 × 10⁴ conidia/ml) using a hand-held atomizer. Control plants were sprayed with sterile distilled water. Plants were placed in a moist chamber at 26°C for 2 days and then transferred to a greenhouse bench where they were kept at 25 to 30°C. Symptoms identical to those observed in the field became visible after 7 to 10 days. Ratings were made 14 days after inoculation by estimating the percentage of leaf area affected using a standard area diagram. Lesions covered 60 to 65% of the leaf area of susceptible cultivars, but less than 2% on resistant cultivars. Control plants remained healthy. C. sojina was reisolated from lesions on leaves of susceptible plants. Above-average rainfall and high relative humidity in northwestern Argentina during the first three months of 2000 may have encouraged the severe outbreak of frogeye leaf spot of soybean. The outbreak was aggravated by the widespread use of notillage systems in the region and the large hectarage planted with susceptible cultivars. References: (1) S.G. Lehman J. Agric. Res. 36:811-833, 1928. (2) D. V. Philips and J. T. Yorinori. 1989. Frogeye leaf spot. Pages 19-21 in: Compendium of Soybean Diseases, 3rd ed. APS Press, St. Paul, MN.

Small bowel bacterial overgrowth in patients with alcoholic cirrhosis

A total of 89 patients with alcoholic cirrhosis and 40 healthy subjects were included in a study to assess the prevalence of intestinal bacterial overgrowth and to analyze its relationship with the severity of liver dysfunction, presence of ascites, and development of spontaneous bacterial peritonitis (SBP). Bacterial overgrowth was measured by means of a breath test after ingestion of glucose. Intestinal bacterial overgrowth was documented in 27 (30.3%) of the 89 patients with alcoholic cirrhosis and in none of the healthy subjects. The prevalence of intestinal bacterial overgrowth was significantly higher in cirrhotics with ascites (37.1%) than in those with no evidence of ascites (5.3%) and among patients with Pugh-Child class C (48.3%) than in patients with a class A (13.1%) or B (27%). Twelve (17.1%) of the 70 patients with ascites developed an episode of SBP. The prevalence of spontaneous bacterial peritonitis was significantly higher in patients who had intestinal bacterial overgrowth (30.7%) than in patients who did not (9.09%). We conclude that intestinal bacterial overgrowth occurs in approximately one third of patients with cirrhosis secondary to alcohol, particularly in patients with ascites and advanced liver dysfunction. Moreover, bacterial overgrowth may be a condition favoring infection of the ascitic fluid.

Small bowel bacterial overgrowth in patients with alcoholic cirrhosis

A total of 89 patients with alcoholic cirrhosis and 40 healthy subjects were included in a study to assess the prevalence of intestinal bacterial overgrowth and to analyze its relationship with the severity of liver dysfunction, presence of ascites, and development of spontaneous bacterial peritonitis (SBP). Bacterial overgrowth was measured by means of a breath test after ingestion of glucose. Intestinal bacterial overgrowth was documented in 27 (30.3%) of the 89 patients with alcoholic cirrhosis and in none of the healthy subjects. The prevalence of intestinal bacterial overgrowth was significantly higher in cirrhotics with ascites (37.1%) than in those with no evidence of ascites (5.3%) and among patients with Pugh-Child class C (48.3%) than in patients with class A (13.1%) or B (27%). Twelve (17.1%) of the 70 patients with ascites developed an episode of SBP. The prevalence of spontaneous bacterial peritonitis was significantly higher in patients who had intestinal bacterial overgrowth (30.7%) than in patients who did not (9.09%). We conclude that intestinal bacterial overgrowth occurs in approximately one third of patients with cirrhosis secondary to alcohol, particularly in patients with ascites and advanced liver dysfunction. Moreover, bacterial overgrowth may be a condition favoring infection of the ascitic fluid.

[Human immunodeficiency virus infection in an emergency department]

Unlabeled serum samples from patients attended at the Emergency Department of our Hospital were collected for a 10-week period to measure the presence of anti-HIV antibodies and assess the prevalence of the infection in this population. Both suspected (with warning mark on samples) and non-suspected patients of having the infection were included. Concurrently, health care personnel in the Emergency Department were asked to complete a questionnaire on issues concerning the knowledge of this infection and the precautions to adopt. The compliance of these measures was verified. Only 3 from the 2,293 samples from nonsuspected patients were positive (0.13%). The 79 samples from suspected patients corresponded to 44 persons with previously known infection and 35 persons engaging in high-risk behaviours; from the latter group 11 were ultimately positive. Although health care personnel was aware of precautions, they only adopted them with suspected patients but incorrectly. Thus, there was inconsistency between the perceived risk by health care personnel and the precautions adopted. While the prevalence of HIV infection is still low in the attended population at the Emergency Department, efforts must be made to decrease accidental exposures, as an increase in its prevalence is to be expected.

Natural killer cell activity in alcoholic cirrhosis: influence of nutrition

Forty-five patients with alcoholic cirrhosis, 20 chronic alcoholics with normal liver function tests and 36 healthy subjects were investigated. A combined index of nine anthropometric and biochemical parameters (triceps skinfold, arm muscle circumference, mid-arm muscle area, body fat percentage, creatinine-height index, serum albumin, plasma transferrin, prealbumin and retinol-binding protein levels) was used to evaluate nutritional status, allowing a distinction to be made between those patients with adequate nutrition (group I: 40 per cent of cirrhotics and 55 per cent of alcoholics), those with slight malnutrition (group II: 37.7 per cent of cirrhotics and 45 per cent of alcoholics) and those with severe malnutrition (group III: 22.2 per cent of cirrhotics and none alcoholic). Natural Killer (NK) cell activity of peripheral blood lymphocytes was determined using a 51Cr releasing cytotoxicity assay against K562 target cells. This was significantly lower in the cirrhotics than in the controls and chronic alcoholics (P less than 0.001 and P less than 0.01 respectively), but there was no difference between the latter two groups. Natural Killer activity was significantly lower in samples obtained from cirrhotics with severe malnutrition than in those with adequate nutrition, suggesting that malnutrition may play a role in the onset of the immunological disorder. No relationship could be established between nutritional status, NK activity and the clinical activity of the disease using Orrego's index on the liver function tests.