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Summary Migrant Chinese populations in Western countries have a high prevalence of chronic hepatitis B but often experience poor access to health care and late diagnosis. This systematic review aimed to identify obstacles and supports to timely and appropriate health service use among these populations. Systematic searches resulted in 48 relevant studies published between 1996 and 2015. Data extraction and synthesis were informed by models of healthcare access that highlight the interplay of patient, provider and health system factors. There was strong consistent evidence of low levels of knowledge among patients and community members; but interventions that were primarily focused on increasing knowledge had only modest positive effects on testing and/or vaccination. There was strong consistent evidence that Chinese migrants tend to misunderstand the need for health care for hepatitis B and have low satisfaction with services. Stigma was consistently associated with hepatitis B, and there was weak but consistent evidence of stigma acting as a barrier to care. However, available evidence on the effects of providing culturally appropriate services for hepatitis B on increasing uptake is limited. There was strong consistent evidence that health professionals miss opportunities for testing and vaccination. Practitioner education interventions may be important, but evidence of effectiveness is limited. A simple prompt in patient records for primary care physicians improved the uptake of testing, and a dedicated service increased targeted vaccination coverage for newborns. Further development and more rigorous evaluation of more holistic approaches that address patient, provider and system obstacles are needed.

Policymakers-Health Commissioners Interview Guide. Interview schedule used for the individual key informant interviews with health commissioners, managers and policymakers. (DOCX 18Â kb)

Vignette and Focus Group Discussion Guide. Example of vignette used for focus group discussions, as well as discussion questions used in all the focus groups. (DOCX 20Â kb)

Community Key Informant Interview Guide. Interview schedule used for the individual key informant interviews with community participants. (DOCX 17Â kb)

Health Practitioner Interview Guide. Interview schedule used for the individual key informant interviews with health practitioners. (DOCX 18Â kb)

SummaryMany viral infections that cause minor illness in younger adults can lead to significant mortality and morbidity in older people, particularly as co-morbidities tend to accumulate with increased age. Respiratory and gastrointestinal viruses are ubiquitous and frequently cause outbreaks, with major impact on those in care homes or residential accommodation. Advances in medicine have opened the way for increased impact of the herpes viruses (varicella zoster virus, herpes simplex virus, Epstein–Barr virus and cytomegalovirus), as immune systems are manipulated. People are also leading more active lives in older age; human immunodeficiency virus (HIV) will be increasingly prevalent, as those living with HIV grow older in good health. In addition, new diagnoses of HIV, viral hepatitis and travel-related infections will present to those working in health care of older people. This review article of viral infections aims to highlight relevant pathology, with specific reference to management in older people.

Background Global migration from hepatitis B endemic countries poses a significant public health challenge in receiving low-prevalence countries. In the UK, Chinese migrants are a high risk group for hepatitis B. However, they are an underserved population that infrequently accesses healthcare. This study sought to increase understanding of the determinants of hepatitis B testing and healthcare access among migrants of Chinese ethnicity living in England. Methods We sought to obtain and integrate insights from different key stakeholders in the system. We conducted six focus group discussions and 20 in-depth interviews with community members and patients identifying themselves as ‘Chinese’, and interviewed 21 clinicians and nine health service commissioners. Data were thematically analysed and findings were corroborated through two validation workshops. Results Three thematic categories emerged: knowledge and awareness, visibility of the disease, and health service issues. Low disease knowledge and awareness levels among community members contributed to erroneous personal risk perception and suboptimal engagement with services. Limited clinician knowledge led to missed opportunities to test and inaccurate assessments of infection risks in Chinese patients. There was little social discourse and considerable stigma linked to the disease among some sub-sections of the Chinese population. A lack of visibility of the issue and the population within the health system meant that these health needs were not prioritised by clinicians or commissioners. Service accessibility was also affected by the lack of language support. Greater use of community outreach, consultation aids, ‘cultural competency’ training, and locally adapted testing protocols may help. Conclusions Hepatitis B among migrants of Chinese ethnicity in England can be characterised as an invisible disease in an invisible population. Multi-modal solutions are needed to tackle barriers within this population and the health system. Electronic supplementary material The online version of this article (10.1186/s12889-017-4796-4) contains supplementary material, which is available to authorized users.

Dexmedetomidine, a highly selective and potent alpha2-adrenergic agonist, has a potentially useful role as a sedative agent in patients requiring intensive care. As part of a larger European multicentre trial, a total of 119 postoperative cardiac and general surgical patients requiring ventilation and sedation in an intensive care unit were enrolled in four centres in the United Kingdom. One hundred and five patients were randomly allocated to receive either dexmedetomidine or placebo with rescue sedation and analgesia provided by midazolam and morphine, respectively. Compared with the control group, intubated patients receiving dexmedetomidine required 80% less midazolam [mean 4.9 (5.8) microg.kg-1.h-1 vs. 23.7 (27.5) microg.kg-1.h-1, p < 0.0001], and 50% less morphine [11.2 (13.4) microg.kg-1.h-1 vs. 21.5 (19.4) microg.kg-1.h-1,p = 0.0006]. Cardiovascular effects and adverse events could be predicted from the known properties of alpha-2 agonists. In conclusion, dexmedetomidine is a useful agent for the provision of postoperative analgesia and sedation.

Background Part of the rationale for transferring public health responsibilities from the NHS to local government in 2013, was that it would give renewed focus to “upstream” preventive interventions, to improve population health and tackle inequalities more effectively. However there is a risk of potential unintended consequences in terms of the impact on commissioning preventive services at the interface between local government and the NHS. Such services may be difficult to prioritise, particularly given the greater visibility and demand for services for treatment of symptomatic conditions. To date, the actual impact of current commissioning arrangements on preventive service commissioning remains unclear. The aim of this work was therefore to identify common themes relating to the current barriers and enablers of commissioning prevention services. Methods Information from interviews and workshops with commissioners and providers were synthesised from two independent projects: a research project exploring barriers to effective management of the Hepatitis B risk in the Chinese community (CATH-B) and a consultation conducted for Public Health England to inform the roll-out of the national Diabetes Prevention Programme (DPP). Data was collected from 23 interviews (3 for DPP; 20 for CATH-B) and 4 workshops (2 for DPP; 2 for CATH-B) for thematic analysis. Findings were discussed with stakeholders to ensure appropriate interpretation and contextualisation. Results Common barriers that emerged from both commissioner and provider perspectives included: lack of clarity regarding commissioning responsibilities; other competing priorities in the context of finite budgets; lack of understanding of the evidence base; lack of perception that prevention was a priority for services driven by increasing urgent demands; the long-term nature of outcomes for preventive services. Potential enablers included making the service a higher priority for commissioners by linking it to national targets and funding and the availability of local community providers with capacity to deliver appropriate services. However, the “top-down” nature, and complexities, of commissioning meant using local community-based providers was not always feasible. Conclusion Since the transfer of responsibility for public health and in a context of shrinking resources, prevention services have been put at risk by lack of clarity about where responsibilities lie, lack of local champions for prevention services in many areas, and complexities of commissioning locally tailored, appropriate and accessible services. Fragmentation and complexity of commissioning responsibilities and lack of clarity about budgets are widely seen as significant barriers to effective commissioning suggesting integrated budgets “place-based” commissioning will be essential to facilitate effective service commissioning and delivery.

To determine whether the therapeutic intervention scoring system (TISS) reliably reflects the cost of the overall intensive care unit (ICU) population, subgroups of that population and individual ICU patients.Prospective analysis of individual patient costs and comparison with TISS.Adult, 12 bedded general medical and surgical ICU in a university teaching hospital.Two hundred fifty-seven consecutive patients including 52 coronary care (CCU), 99 cardiac surgery (CS) and 106 general ICU (GIC) cases admitted to the ICU during a 12-week period in 1994. A total of 916 TISS-scored patient days were analysedA variable cost (VC) that included consumables and service usage (nursing, physiotherapy, radiology and pathology staff costs) for individual patients was measured daily. Nursing costs were calculated in proportion to a daily nursing dependency score. A fixed cost (FC) was calculated for each patient to include medical, technical and clerical salary costs, capital equipment depreciation, equipment and central hospital costs. The correlation between cost and TISS was analysed using regression analysis.For the whole group (n = 257) the average daily FC was pound sterling 255 and daily VC was pound sterling 541 (SEM 10); range pound sterling 23-pound sterling 2,806. In the patient subgroups average daily cost (FC + VC) for CCU was pound sterling 476 (SEM 17.5), for CS pound sterling 766 (SEM 13.8) and for GIC pound sterling 873 (SEM 13.6). In the group as a whole, a strong correlation was demonstrated between VC and the TISS for each patient day (r = 0.87, p0.001) and this improved further when the total TISS score was compared with the total VC of the entire patient episode (r = 0.93, p0.001). This correlation was maintained in CCU, CS and GIC patient cohorts with only a small median difference between actual and predicted cost (2.2 % for GIC patients). However, in the individual patient, the range of error was up to +/- 65 % of the true variable cost. For the whole group the variable cost per TISS point was pound sterling 25.These results demonstrate that TISS reliably measures overall ICU population costs as well as those of the subgroups CCU, CS and GIC. However, the relationship between TISS and cost is less reliable for the individual patient.