A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia:the ECLIPSE trial

BACKGROUND: Heavy menstrual bleeding (HMB) is a common problem, yet evidence to inform decisions about initial medical treatment is limited. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena(®), Bayer) compared with usual medical treatment, with exploration of women's perspectives on treatment. DESIGN: A pragmatic, multicentre randomised trial with an economic evaluation and a longitudinal qualitative study. SETTING: Women who presented in primary care. PARTICIPANTS: A total of 571 women with HMB. A purposeful sample of 27 women who were randomised or ineligible owing to treatment preference participated in semistructured face-to-face interviews around 2 and 12 months after commencing treatment. INTERVENTIONS: LNG-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone). Women could subsequently swap or cease their allocated treatment. OUTCOME MEASURES: The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period and then again at 5 years. Secondary outcomes included general quality of life (QoL), sexual activity, surgical intervention and safety. Data were analysed using iterative constant comparison. A state transition model-based cost-utility analysis was undertaken alongside the randomised trial. Quality-adjusted life-years (QALYs) were derived from the European Quality of Life-5 Dimensions (EQ-5D) and the Short Form questionnaire-6 Dimensions (SF-6D). The intention-to-treat analyses were reported as cost per QALY gained. Uncertainty was explored by conducting both deterministic and probabilistic sensitivity analyses. RESULTS: The MMAS total scores improved significantly in both groups at all time points, but were significantly greater for the LNG-IUS than for usual treatment [mean difference over 2 years was 13.4 points, 95% confidence interval (CI) 9.9 to 16.9 points; p < 0.001]. However, this difference between groups was reduced and no longer significant by 5 years (mean difference in scores 3.9 points, 95% CI -0.6 to 8.3 points; p = 0.09). By 5 years, only 47% of women had a LNG-IUS in place and 15% were still taking usual medical treatment. Five-year surgery rates were low, at 20%, and were similar, irrespective of initial treatments. There were no significant differences in serious adverse events between groups. Using the EQ-5D, at 2 years, the relative cost-effectiveness of the LNG-IUS compared with usual medical treatment was £1600 per QALY, which by 5 years was reduced to £114 per QALY. Using the SF-6D, usual medical treatment dominates the LNG-IUS. The qualitative findings show that women's experiences and expectations of medical treatments for HMB vary considerably and change over time. Women had high expectations of a prompt effect from medical treatments. CONCLUSIONS: The LNG-IUS, compared with usual medical therapies, resulted in greater improvement over 2 years in women's assessments of the effect of HMB on their daily routine, including work, social and family life, and psychological and physical well-being. At 5 years, the differences were no longer significant. A similar low proportion of women required surgical intervention in both groups. The LNG-IUS is cost-effective in both the short and medium term, using the method generally recommended by the National Institute for Health and Care Excellence. Using the alternative measures to value QoL will have a considerable impact on cost-effectiveness decisions. It will be important to explore the clinical and health-care trajectories of the ECLIPSE (clinical effectiveness and cost-effectiveness of levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia) trial participants to 10 years, by which time half of the cohort will have reached menopause. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86566246. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 88. See the NIHR Journals Library website for further project information.

Assembly of a high-dielectric constant thin TiOX layer directly on H-terminated semiconductor diamond

A high-dielectric constant (high-k) TiOx thin layer was fabricated on hydrogen-terminated diamond (H-diamond) surface by low temperature oxidation of a thin titanium layer in ambient air. The metallic titanium layer was deposited by sputter deposition. The dielectric constant of the resultant TiOx was calculated to be around 12. The capacitance density of the metal-oxide-semiconductor (MOS) based on the TiOx/H-diamond was as high as 0.75 µF/cm2 contributed from the high-k value and the very thin thickness of the TiOx layer. The leakage current was lower than 10-13 A at reverse biases and 10-7A at the forward bias of -2 V. The MOS field-effect transistor based on the high-k TiOx/H-diamond was demonstrated. The utilization of the high-k TiOx with a very thin thickness brought forward the features of an ideally low subthreshold swing slope of 65 mV per decade and improved drain current at low gate voltages. The advantages of the utilization high-k dielectric for diamond MOSFETs are anticipated.

Vacuum spacetimes with constant Weyl eigenvalues

Einstein spacetimes (that is vacuum spacetimes possibly with a non-zero cosmological constant A) with constant non-zero Weyl eigenvalues are considered. For type Petrov II & D this assumption allows one to prove that the non-repeated eigenvalue necessarily has the value 2A/3 and it turns out that the only possible spacetimes are some Kundt-waves considered by Lewandowski which are type II and a Robinson-Bertotti solution of type D. For Petrov type I the only solution turns out to be a homogeneous pure vacuum solution found long ago by Petrov using group theoretic methods. These results can be summarised by the statement that the only vacuum spacetimes with constant Weyl eigenvalues are either homogeneous or are Kundt spacetimes. This result is similar to that of Coley et al. who proved their result for general spacetimes under the assumption that all scalar invariants constructed from the curvature tensor and all its derivatives were constant.

Constant V/Hz control based on DSP for open winding doubly-fed wind power generator

A DSP implementation of Space Vector PWM (SVPWM) using constant V/Hz control for the open winding doubly-fed generator is proposed. This control of SVPWM modulation mode and open winding structure combination has the high voltage utilization ratio, greatly improves the control precision of the system, and reduces the stator winding output current distortion rate, though the complexity of the system is increased. This paper describes the basic principle of SVPWM and discusses the particularity of SVPWM waveform generated by hybrid vector under the condition of open winding. This method is applied to a state of doubly-fed wind power generator. The experimental verification shows that this control method can make the output voltage amplitude of the doubly-fed induction generator be 380V and the frequency be 50Hz by using of TMS32028335 chip based on constant V/Hz control of symmetric SVPWM modulation wave.

Intelligent outcome measures in liaison psychiatry:essential even if not desirable. Commentary on... a multidimensional Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP)

Service development is guided by outcome measures that inform service commissioners and providers. Those in liaison psychiatry should be encouraged to develop a positive approach that integrates the collection of outcome measures into everyday clinical practice. The Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP) is a very useful tool to measure service quality and clinical effectiveness, using a combination of clinician-rated and patient-rated outcome measures and patient-rated experience measures. However, it does not include measures of cost-effectiveness or training activities. The FROM-LP is a significant step towards developing nationally unified outcome measures.