Cost-effectiveness of ticagrelor and generic clopidogrel in patients with acute coronary syndrome in Switzerland

QUESTION UNDER STUDY The aim of this study was to evaluate the cost-effectiveness of ticagrelor and generic clopidogrel as add-on therapy to acetylsalicylic acid (ASA) in patients with acute coronary syndrome (ACS), from a Swiss perspective. METHODS Based on the PLATelet inhibition and patient Outcomes (PLATO) trial, one-year mean healthcare costs per patient treated with ticagrelor or generic clopidogrel were analysed from a payer perspective in 2011. A two-part decision-analytic model estimated treatment costs, quality-adjusted life years (QALYs), life years and the cost-effectiveness of ticagrelor and generic clopidogrel in patients with ACS up to a lifetime at a discount of 2.5% per annum. Sensitivity analyses were performed. RESULTS Over a patient's lifetime, treatment with ticagrelor generates an additional 0.1694 QALYs and 0.1999 life years at a cost of CHF 260 compared with generic clopidogrel. This results in an Incremental Cost Effectiveness Ratio (ICER) of CHF 1,536 per QALY and CHF 1,301 per life year gained. Ticagrelor dominated generic clopidogrel over the five-year and one-year periods with treatment generating cost savings of CHF 224 and 372 while gaining 0.0461 and 0.0051 QALYs and moreover 0.0517 and 0.0062 life years, respectively. Univariate sensitivity analyses confirmed the dominant position of ticagrelor in the first five years and probabilistic sensitivity analyses showed a high probability of cost-effectiveness over a lifetime. CONCLUSION During the first five years after ACS, treatment with ticagrelor dominates generic clopidogrel in Switzerland. Over a patient's lifetime, ticagrelor is highly cost-effective compared with generic clopidogrel, proven by ICERs significantly below commonly accepted willingness-to-pay thresholds.

Up-Scaling Sustainable Pro-Poor Energy Solutions: Addressing Stumbling Blocks

The session aims at analyzing efforts in up-scaling cleaner and more efficient energy solutions for poor people in developing countries by addressing the following questions: What are factors along the whole value chain and in the institutional, social, but also environmental space that enable up-scaling of improved pro-poor technologies? Are there differences between energy carriers or in different contexts? What are most promising entry points for up-scaling?

Service level agreements-driven management of distributed applications in cloud computing environments

Advancements in cloud computing have enabled the proliferation of distributed applications, which require management and control of multiple services. However, without an efficient mechanism for scaling services in response to changing workload conditions, such as number of connected users, application performance might suffer, leading to violations of Service Level Agreements (SLA) and possible inefficient use of hardware resources. Combining dynamic application requirements with the increased use of virtualised computing resources creates a challenging resource Management context for application and cloud-infrastructure owners. In such complex environments, business entities use SLAs as a means for specifying quantitative and qualitative requirements of services. There are several challenges in running distributed enterprise applications in cloud environments, ranging from the instantiation of service VMs in the correct order using an adequate quantity of computing resources, to adapting the number of running services in response to varying external loads, such as number of users. The application owner is interested in finding the optimum amount of computing and network resources to use for ensuring that the performance requirements of all her/his applications are met. She/he is also interested in appropriately scaling the distributed services so that application performance guarantees are maintained even under dynamic workload conditions. Similarly, the infrastructure Providers are interested in optimally provisioning the virtual resources onto the available physical infrastructure so that her/his operational costs are minimized, while maximizing the performance of tenants’ applications. Motivated by the complexities associated with the management and scaling of distributed applications, while satisfying multiple objectives (related to both consumers and providers of cloud resources), this thesis proposes a cloud resource management platform able to dynamically provision and coordinate the various lifecycle actions on both virtual and physical cloud resources using semantically enriched SLAs. The system focuses on dynamic sizing (scaling) of virtual infrastructures composed of virtual machines (VM) bounded application services. We describe several algorithms for adapting the number of VMs allocated to the distributed application in response to changing workload conditions, based on SLA-defined performance guarantees. We also present a framework for dynamic composition of scaling rules for distributed service, which used benchmark-generated application Monitoring traces. We show how these scaling rules can be combined and included into semantic SLAs for controlling allocation of services. We also provide a detailed description of the multi-objective infrastructure resource allocation problem and various approaches to satisfying this problem. We present a resource management system based on a genetic algorithm, which performs allocation of virtual resources, while considering the optimization of multiple criteria. We prove that our approach significantly outperforms reactive VM-scaling algorithms as well as heuristic-based VM-allocation approaches.

The application of latent variable models to the assessment of determinants of HIV risk behavior

Studies on the relationship between psychosocial determinants and HIV risk behaviors have produced little evidence to support hypotheses based on theoretical relationships. One limitation inherent in many articles in the literature is the method of measurement of the determinants and the analytic approach selected. ^ To reduce the misclassification associated with unit scaling of measures specific to internalized homonegativity, I evaluated the psychometric properties of the Reactions to Homosexuality scale in a confirmatory factor analytic framework. In addition, I assessed the measurement invariance of the scale across racial/ethnic classifications in a sample of men who have sex with men. The resulting measure contained eight items loading on three first-order factors. Invariance assessment identified metric and partial strong invariance between racial/ethnic groups in the sample. ^ Application of the updated measure to a structural model allowed for the exploration of direct and indirect effects of internalized homonegativity on unprotected anal intercourse. Pathways identified in the model show that drug and alcohol use at last sexual encounter, the number of sexual partners in the previous three months and sexual compulsivity all contribute directly to risk behavior. Internalized homonegativity reduced the likelihood of exposure to drugs, alcohol or higher numbers of partners. For men who developed compulsive sexual behavior as a coping strategy for internalized homonegativity, there was an increase in the prevalence odds of risk behavior. ^ In the final stage of the analysis, I conducted a latent profile analysis of the items in the updated Reactions to Homosexuality scale. This analysis identified five distinct profiles, which suggested that the construct was not homogeneous in samples of men who have sex with men. Lack of prior consideration of these distinct manifestations of internalized homonegativity may have contributed to the analytic difficulty in identifying a relationship between the trait and high-risk sexual practices. ^

Early identification of symptomatic aortic stenosis using echocardiographic data

Background: Heart failure (CHF) is the most frequent and prognostically severe symptom of aortic stenosis (AS), and the most common indication for surgery. The mainstay of treatment for AS is aortic valve replacement (AVR), and the main indication for an AVR is development of symptomatic disease. ACC/AHA guidelines define severe AS as an aortic valve area (AVA) ≤1cm², but there is little data correlating echocardiogram AVA with the onset of symptomatic CHF. We evaluated the risk of developing CHF with progressively decreasing echocardiographic AVA. We also compared echocardiographic AVA with Jet velocity (V2) and indexed AVA (AVAI) to assess the best predictor of development of symptomatic CHF.^ Methods and Results: This retrospective cohort study evaluated 518 patients with asymptomatic moderate or severe AS from a single community based cardiology practice. A total of 925 echocardiograms were performed over an 11-year period. Each echocardiogram was correlated with concurrent clinical assessments while the investigator was blinded to the echocardiogram severity of AS. The Cox Proportional hazards model was used to analyze the relationship between AVA and the development of CHF. The median age of patients at entry was 76.1 years, with 54% males. A total of 116 patients (21.8%) developed new onset CHF during follow-up. Compared to patients with AVA >1.0cm², patients with lower AVA had an exponentially increasing risk of developing CHF for each 0.2cm² decrement in AVA, becoming statistically significant only at an AVA less than 0.8 cm². Also, compared to V2 and AVAI, AVA added more information to assessing risk for development of CHF (p=0.041). ^ Conclusion: In patients with normal or mildly impaired LVEF, the risk of CHF rises exponentially with decreasing valve area and becomes statistically significant after AVA falls below 0.8cm². AVA is a better predictor of CHF when compared to V2 or AVAI.^

Trastuzumab use and risk of congestive heart failure in older breast cancer patients

Trastuzumab is a humanized-monoclonal antibody, developed specifically for HER2-neu over-expressed breast cancer patients. Although highly effective and well tolerated, it was reported associated with Congestive Heart Failure (CHF) in clinical trial settings (up to 27%). This leaves a gap where, Trastuzumab-related CHF rate in general population, especially older breast cancer patients with long term treatment of Trastuzumab remains unknown. This thesis examined the rates and risk factors associated with Trastuzumab-related CHF in a large population of older breast cancer patients. A retrospective cohort study using the existing Surveillance, Epidemiology and End Results (SEER) and Medicare linked de-identified database was performed. Breast cancer patients ≥ 66 years old, stage I-IV, diagnosed in 1998-2007, fully covered by Medicare but no HMO within 1-year before and after first diagnosis month, received 1st chemotherapy no earlier than 30 days prior to diagnosis were selected as study cohort. The primary outcome of this study is a diagnosis of CHF after starting chemotherapy but none CHF claims on or before cancer diagnosis date. ICD-9 and HCPCS codes were used to pool the claims for Trastuzumab use, chemotherapy, comorbidities and CHF claims. Statistical analysis including comparison of characteristics, Kaplan-Meier survival estimates of CHF rates for long term follow up, and Multivariable Cox regression model using Trastuzumab as a time-dependent variable were performed. Out of 17,684 selected cohort, 2,037 (12%) received Trastuzumab. Among them, 35% (714 out of 2037) were diagnosed with CHF, compared to 31% (4784 of 15647) of CHF rate in other chemotherapy recipients (p<.0001). After 10 years of follow-up, 65% of Trastuzumab users developed CHF, compared to 47% in their counterparts. After adjusting for patient demographic, tumor and clinical characteristics, older breast cancer patients who used Trastuzumab showed a significantly higher risk in developing CHF than other chemotherapy recipients (HR 1.69, 95% CI 1.54 - 1.85). And this risk is increased along with the increment of age (p-value < .0001). Among Trastuzumab users, these covariates also significantly increased the risk of CHF: older age, stage IV, Non-Hispanic black race, unmarried, comorbidities, Anthracyclin use, Taxane use, and lower educational level. It is concluded that, Trastuzumab users in older breast cancer patients had 69% higher risk in developing CHF than non-Trastuzumab users, much higher than the 27% increase reported in younger clinical trial patients. Older age, Non-Hispanic black race, unmarried, comorbidity, combined use with Anthracycline or Taxane also significantly increase the risk of CHF development in older patients treated with Trastuzumab. ^

Data compilation of respiration, feeding, and growth rates of marine pelagic organisms

The metabolic rate of organisms may either be viewed as a basic property from which other vital rates and many ecological patterns emerge and that follows a universal allometric mass scaling law; or it may be considered a property of the organism that emerges as a result of the organism's adaptation to the environment, with consequently less universal mass scaling properties. Data on body mass, maximum ingestion and clearance rates, respiration rates and maximum growth rates of animals living in the ocean epipelagic were compiled from the literature, mainly from original papers but also from previous compilations by other authors. Data were read from tables or digitized from graphs. Only measurements made on individuals of know size, or groups of individuals of similar and known size were included. We show that clearance and respiration rates have life-form-dependent allometries that have similar scaling but different elevations, such that the mass-specific rates converge on a rather narrow size-independent range. In contrast, ingestion and growth rates follow a near-universal taxa-independent ~3/4 mass scaling power law. We argue that the declining mass-specific clearance rates with size within taxa is related to the inherent decrease in feeding efficiency of any particular feeding mode. The transitions between feeding mode and simultaneous transitions in clearance and respiration rates may then represent adaptations to the food environment and be the result of the optimization of tradeoffs that allow sufficient feeding and growth rates to balance mortality.

NDT for concrete under accelerated freeze/thaw tests and surface scaling

Freezing of water or salt solution in concrete pores is a main cause for severe damage and significant reduction of the service life. Most of the freeze-thaw (F-T) accelerated tests measure the scaling of concrete by weighting. This paper presents complementary procedures based on the use of strain gages and ultrasonic pulse velocity (UPV) for measuring the deterioration of concrete due to freezing and thawing. These non-destructive testing (NDT) procedures are applied to two types of concretes, one susceptible to F-T damage and the other does not. The results show a good correlation between scaling and the measurements obtained with NDT. Showing NDT the advantage to detect before the damage and to perform continuous measurement

Study of the damage evolution of the concrete under freeze-thaw cycles using traditional and non-traditional techniques

Some experiments have been performed to investigate the cyclic freeze-thaw deterioration of concrete, using traditional and non-traditional techniques. Two concrete mixes, with different pore structure, were tested in order to compare the behavior of a freeze-thaw resistant concrete from one that is not. One of the concretes was air entrained, high content of cement and low w/c ratio, and the other one was a lower cement content and higher w/c ratio, without air-entraining agent. Concrete specimens were studied under cyclic freeze-thaw conditions according to UNE-CENT/TS 12390-9 test, using 3% NaCl solution as freezing medium (CDF test: Capillary Suction, De-icing agent and Freeze-thaw Test). The temperature and relative humidity were measured during the cycles inside the specimens using embedded sensors placed at different heights from the surface in contact with the de-icing agent solution. Strain gauges were used to measure the strain variations at the surface of the specimens. Also, measurements of ultrasonic pulse velocity through the concrete specimens were taken before, during, and after the freeze-thaw cycles. According to the CDF test, the failure of the non-air-entraining agent concrete was observed before 28 freeze-thaw cycles; contrariwise, the scaling of the air-entraining agent concrete was only 0.10 kg/m 2 after 28 cycles, versus 3.23 kg/m 2 in the deteriorated concrete, after 28 cycles. Similar behavior was observed on the strain measurements. The residual strain in the deteriorated concrete after 28 cycles was 1150 m versus 65 m, in the air-entraining agent concrete. By means of monitoring the changes of ultrasonic pulse velocity during the freeze-thaw cycles, the deterioration of the tested specimens were assessed

Computer simulation of the interplay between fractal structures and surrounding heterogeneous multifractal distributions. Applications

In a large number of physical, biological and environmental processes interfaces with high irregular geometry appear separating media (phases) in which the heterogeneity of constituents is present. In this work the quantification of the interplay between irregular structures and surrounding heterogeneous distributions in the plane is made For a geometric set image and a mass distribution (measure) image supported in image, being image, the mass image gives account of the interplay between the geometric structure and the surrounding distribution. A computation method is developed for the estimation and corresponding scaling analysis of image, being image a fractal plane set of Minkowski dimension image and image a multifractal measure produced by random multiplicative cascades. The method is applied to natural and mathematical fractal structures in order to study the influence of both, the irregularity of the geometric structure and the heterogeneity of the distribution, in the scaling of image. Applications to the analysis and modeling of interplay of phases in environmental scenarios are given.

Contribution of S opponent cells to color appearance

We measured the regions in isoluminant color space over which observers perceive red, yellow, green, and blue and examined the extent to which the colors vary in perceived amount within these regions. We compared color scaling of various isoluminant stimuli by using large spots, which activate all cone types, to that with tiny spots in the central foveola, where S cones, and thus S opponent (So) cell activity, are largely or entirely absent. The addition of So input to that from the L and M opponent cells changes the chromatic appearance of all colors, affecting each primary color in different chromatic regions in the directions and by the amount predicted by our color model. Shifts from white to the various chromatic stimuli we used produced sinusoidal variations in cone activation as a function of color angle for each cone type and in the responses of lateral geniculate cells. However, psychophysical color-scaling functions for 2° spots were nonsinusoidal, being much more peaked. The color-scaling functions are well fit by sine waves raised to exponents between 1 and 3. The same is true for the color responses of a large subpopulation of striate cortex cells. The narrow color tuning, the discrepancies between the spectral loci of the peaks of the color-scaling curves and those of lateral geniculate cells, and the changes in color appearance produced by eliminating So input provide evidence for a cortical processing stage at which the color axes are rotated by a combination of the outputs of So cells with those of L and M opponent cells in the manner that we postulated earlier. There seems to be an expansive response nonlinearity at this stage.

Statistical analysis of shape of objects based on landmark data.

Two objects with homologous landmarks are said to be of the same shape if the configurations of landmarks of one object can be exactly matched with that of the other by translation, rotation/reflection, and scaling. The observations on an object are coordinates of its landmarks with reference to a set of orthogonal coordinate axes in an appropriate dimensional space. The origin, choice of units, and orientation of the coordinate axes with respect to an object may be different from object to object. In such a case, how do we quantify the shape of an object, find the mean and variation of shape in a population of objects, compare the mean shapes in two or more different populations, and discriminate between objects belonging to two or more different shape distributions. We develop some methods that are invariant to translation, rotation, and scaling of the observations on each object and thereby provide generalizations of multivariate methods for shape analysis.