Cost-benefit evaluation of routine influenza immunisation in people 65-74 years of age

OBJECTIVES: To determine the cost-effectiveness of influenza vaccination in people aged 65-74 years in the absence of co-morbidity. DESIGN: Primary research: randomised controlled trial. SETTING: Primary care. PARTICIPANTS: People without risk factors for influenza or contraindications to vaccination were identified from 20 general practitioner (GP) practices in Liverpool in September 1999 and invited to participate in the study. There were 5875/9727 (60.4%) people aged 65-74 years identified as potentially eligible and, of these, 729 (12%) were randomised. INTERVENTION: Participants were randomised to receive either influenza vaccine or placebo (ratio 3:1), with all individuals receiving pneumococcal vaccine unless administered in the previous 10 years. Of the 729 people randomised, 552 received vaccine and 177 received placebo; 726 individuals were administered pneumococcal vaccine. MAIN OUTCOME MEASURES AND METHODOLOGY OF ECONOMIC EVALUATION: GP attendance with influenza-like illness (ILI) or pneumonia (primary outcome measure); or any respiratory symptoms; hospitalisation with a respiratory illness; death; participant self-reported ILI; quality of life (QoL) measures at 2, 4 and 6 months post-study vaccination; adverse reactions 3 days after vaccination. A cost-effectiveness analysis was undertaken to identify the incremental cost associated with the avoidance of episodes of influenza in the vaccination population and an impact model was used to extrapolate the cost-effectiveness results obtained from the trial to assess their generalisability throughout the NHS. RESULTS: In England and Wales, weekly consultations for influenza and ILI remained at baseline levels (less than 50 per 100,000 population) until week 50/1999 and then increased rapidly, peaking during week 2/2000 with a rate of 231/100,000. This rate fell within the range of 'higher than expected seasonal activity' of 200-400/100,000. Rates then quickly declined, returning to baseline levels by week 5/2000. The predominant circulating strain during this period was influenza A (H3N2). Five (0.9%) people in the vaccine group were diagnosed by their GP with an ILI compared to two (1.1%) in the placebo group [relative risk (RR), 0.8; 95% confidence interval (CI) = 0.16 to 4.1]. No participants were diagnosed with pneumonia by their GP and there were no hospitalisations for respiratory illness in either group. Significantly fewer vaccinated individuals self-reported a single ILI (4.6% vs 8.9%, RR, 0.51; 95% CI for RR, 0.28 to 0.96). There was no significant difference in any of the QoL measurements over time between the two groups. Reported systemic side-effects showed no significant differences between groups. Local side-effects occurred with a significantly increased incidence in the vaccine group (11.3% vs 5.1%, p = 0.02). Each GP consultation avoided by vaccination was estimated from trial data to generate a net NHS cost of 174 pounds. CONCLUSIONS: No difference was seen between groups for the primary outcome measure, although the trial was underpowered to demonstrate a true difference. Vaccination had no significant effect on any of the QoL measures used, although vaccinated individuals were less likely to self-report ILI. The analysis did not suggest that influenza vaccination in healthy people aged 65-74 years would lead to lower NHS costs. Future research should look at ways to maximise vaccine uptake in people at greatest risk from influenza and also the level of vaccine protection afforded to people from different age and socio-economic populations.

Is influenza vaccination cost effective for healthy people between ages 65 and 74 years? A randomised controlled trial

The aim of this study was to determine the cost effectiveness of influenza vaccination for healthy people aged 65-74 years living in the UK. People without risk factors for influenza (chronic heart, lung or renal disease, diabetic, immuno-suppressed or those living in an institution) were identified from 20 general practitioner (GP) practices in Liverpool in September 1999. 729/5875 (12.4%) eligible individuals were recruited and randomised to receive either influenza vaccine or placebo (ratio 3: 1)! with all participants receiving 23-valent-pneumococcal polysaccharide vaccine unless already administered. The primary analysis was the frequency of influenza as recorded by a GP diagnosis of pneumonia or influenza like illness. In 2000, the UK vaccination policy was changed with influenza vaccine becoming available. for all people aged 65 years and over irrespective of risk. As a consequence of this policy change. the study had to be fundamentally restructured and only results obtained over a one rather than the originally planned two-year randomised controlled trial framework were used. Results from 1999/2000 demonstrated no significant difference between groups for the primary outcome (relative risk 0.8, 95%, CI 0.16-4.1). In addition. there were no deaths or hospitalisations for influenza associated respiratory illness in either group. The subsequent analysis. using both national and local sources of evidence, estimated the following cost effectiveness indicators: (1) incremental NHS cost per GP consultation avoided = pound2000; (2) incremental NHS cost per hospital admission avoided = pound61,000: (3) incremental NHS cost per death avoided = pound1.900.000 and (4) incremental NHS cost per QALY gained = pound304,000. The analysis suggested that influenza vaccination in this Population would not be cost effective. (C) 2004 Elsevier Ltd. All rights reserved.

Affinity purification of 61- and 65-kDa rat brain corticotropin-releasing factor receptors and receptor-associated G proteins.

Corticotropin-releasing factor (CRF) has been shown to have a central role in physiological adaptation to stress. It is recognized for stimulating the release of adrenocorticotropin from the anterior pituitary gland, and has more recently been implicated as a regulator of autonomic and immunological responses to stress. Much confusion has surrounded the characterization of CRF receptors, with proteins of varying molecular weights having been identified but never purified and characterized. Recently, two CRF receptors have been cloned from brain and pituitary gland, but evidence from in-situ hybridization studies suggests that further CRF receptor types exist. We therefore developed two techniques which enable the isolation of CRF receptors from whole rat brain. The use of a solid-phase CRF analogue affinity column and elution using a competing ligand resulted in the purification of a single protein of 61 kDa. A second technique was devised which allowed the co-isolation of associated signalling proteins and the identification of CRF bound species following purification. CRF was covalently cross-linked to receptors and the complex purified using antibodies specific for the ligand. This enabled the purification of a CRF receptor of approximately 65 kDa and associated alpha and beta gamma G protein subunits. This study demonstrates the successful isolation of CRF receptors which are of different molecular weights to those previously observed from affinity cross-linking studies or predicted from cloned genes. In addition, we confirm the involvement of G proteins in CRF stimulated cell signalling by demonstrating their association with purified CRF receptor.

Does a structured gardening programme improve well-being In young-onset dementia? A preliminary study

Introduction: Young onset dementia (YOD) affects about 1 in 1500 people aged under 65 years in the UK. It is associated with loss of employment, independence and an increase in psychological distress. This project set out to identify the benefits of a 2 hour week) structured activity programme of gardening for people with YOD. Method: A mixed qualitative quantitative study of therapeutic gardening for people with YOD, measuring outcomes for both participants with YOD and their carers. 12 participants were recruited from a county wide older adults mental health service, based on onset of dementia being before 65 years of age(range 43-65 years). 2 dropped out and 1 died during the project. Measures included the Mini Mental State Examination, Bradford Well Being Profile, Large Allen Cognitive Level Screen and Pool Activity Level. Results: Over a one year period the carers of the people with YOD found that the project had given participants a renewed sense of purpose and increased well-being. while cognitive functioning declined. Conclusions: This study suggests that a meaningful guided activity programme can maintain or improve well-being in the presence of cognitive deterioration.

An ultimatum bargaining experiment on trade union efficiency

We present an ultimatum wage bargaining experiment showing that a trade union facilitating non-binding communication among workers, raises wages by simultaneously increasing employers’ posted offers and toughening the bargaining position of employees, without reducing overall market efficiency.

Updated radiative forcing estimates of 65 halocarbons and nonmethane hydrocarbons

The direct radiative forcing of 65 chlorofluorocarbons, hydrochlorofluorocarbons, hydrofluorocarbons, hydrofluoroethers, halons, iodoalkanes, chloroalkanes, bromoalkanes, perfluorocarbons and nonmethane hydrocarbons has been evaluated using a consistent set of infrared absorption cross sections. For the radiative transfer models, both line-by-line and random band model approaches were employed for each gas. The line-by-line model was first validated against measurements taken by the Airborne Research Interferometer Evaluation System (ARIES) of the U.K. Meteorological Office; the computed spectrally integrated radiance of agreed to within 2% with experimental measurements. Three model atmospheres, derived from a three-dimensional climatology, were used in the radiative forcing calculations to more accurately represent hemispheric differences in water vapor, ozone concentrations, and cloud cover. Instantaneous, clear-sky radiative forcing values calculated by the line-by-line and band models were in close agreement. The band model values were subsequently modified to ensure exact agreement with the line-by-line model values. Calibrated band model radiative forcing values, for atmospheric profiles with clouds and using stratospheric adjustment, are reported and compared with previous literature values. Fourteen of the 65 molecules have forcings that differ by more than 15% from those in the World Meteorological Organization [1999] compilation. Eleven of the molecules have not been reported previously. The 65-molecule data set reported here is the most comprehensive and consistent database yet available to evaluate the relative impact of halocarbons and hydrocarbons on climate change.

(65)Zn(2+) transport by isolated gill epithelial cells of the American lobster, Homarus americanus

Gills are the first site of impact by metal ions in contaminated waters. Work on whole gill cells and metal uptake has not been reported before in crustaceans. In this study, gill filaments of the American lobster, Homarus americanus, were dissociated in physiological saline and separated into several cell types on a 30, 40, 50, and 80% sucrose gradient. Cells from each sucrose solution were separately resuspended in physiological saline and incubated in (65)Zn(2+) in order to assess the nature of metal uptake by each cell type. Characteristics of zinc accumulation by each kind of cell were investigated in the presence and absence of 10 mM calcium, variable NaCl concentrations and pH values, and 100 mu M verapamil, nifedipine, and the calcium ionophore A23187. (65)Zn(2+) influxes were hyperbolic functions of zinc concentration (1-1,000 mu M) and followed Michaelis-Menten kinetics. Calcium reduced both apparent zinc binding affinity (K (m)) and maximal transport velocity (J (max)) for 30% sucrose cells, but doubled the apparent maximal transport velocity for 80% sucrose cells. Results suggest that calcium, sodium, and protons enter gill epithelial cells by an endogenous broad-specificity cation channel and trans-stimulate metal uptake by a plasma membrane carrier system. Differences in zinc transport observed between gill epithelial cell types appear related to apparent affinity differences of the transporters in each kind of cell. Low affinity cells from 30% sucrose were inhibited by calcium, while high affinity cells from 80% sucrose were stimulated. (65)Zn(2+) transport was also studied by isolated, intact, gill filament tips. These intact gill fragments generally displayed the same transport properties as did cells from 80% sucrose and provided support for metal uptake processes being an apical phenomenon. A working model for zinc transport by lobster gill cells is presented.

Temperature Dependence of the Intergranular Critical Current Density in Uniaxially Pressed Bi(1.65)Pb(0.35)Sr(2)Ca(2)Cu(3)O(10+delta) Samples

We have studied the normal and superconducting transport properties of Bi(1.65)Pb(0.35)Sr(2)Ca(2)Cu(3)O(10+delta) (Bi-2223) ceramic samples. Four samples, from the same batch, were prepared by the solid-state reaction method and pressed uniaxially at different compacting pressures, ranging from 90 to 250 MPa before the last heat treatment. From the temperature dependence of the electrical resistivity, combined with current conduction models for cuprates, we were able to separate contributions arising from both the grain misalignment and microstructural defects. The behavior of the critical current density as a function of temperature at zero applied magnetic field, J (c) (T), was fitted to the relationship J (c) (T)ae(1-T/T (c) ) (n) , with na parts per thousand 2 in all samples. We have also investigated the behavior of the product J (c) rho (sr) , where rho (sr) is the specific resistance of the grain-boundary. The results were interpreted by considering the relation between these parameters and the grain-boundary angle, theta, with increasing the uniaxial compacting pressure. We have found that the above type of mechanical deformation improves the alignment of the grains. Consequently the samples exhibit an enhance in the intergranular properties, resulting in a decrease of the specific resistance of the grain-boundary and an increase in the critical current density.

Avaliação de processo do Programa de Regionalização do Turismo em 65 municípios turísticos brasileiros

Este estudo apresenta uma pesquisa realizada em 65 municípios turísticos brasileiros, no período de dezembro de 2007 a fevereiro de 2008, cujo objetivo é avaliar a implementação do Programa de Regionalização do Turismo nesses municípios. Este programa é o eixo principal das políticas públicas do turismo brasileiro, lançado pelo Ministério do Turismo em 2004. Para compreensão dessa política pública do turismo, realizou-se uma pesquisa documental nos arquivos do Ministério do Turismo, neste descrevem-se o Plano Nacional de Turismo (2003-2007) e o Programa de Regionalização do Turismo; também se realizou uma revisão de literatura sobre os princípios e conceitos em que se alicerça o programa: descentralização participativa, integração, sustentabilidade e a elaboração de uma matriz para avaliação de processo utilizada neste trabalho. Faziam parte da pesquisa as 27 capitais estaduais, o Distrito Federal e mais 37 municípios localizados em consolidados destinos turísticos (Floresta Amazônica, Pantanal Mato-grossense, Serras Gaúchas, Cidades Históricas de Minas, Litoral do Nordeste e outros). Por meio da pesquisa de campo e observação sistemática in loco, 23 pesquisadores coletaram informações dos gestores de turismo locais, utilizando-se de formulários fechados. Estes formulários forma elaborados tendo em vista os objetivos dos nove módulos operacionais previstos no Programa de Regionalização do Turismo e seus indicadores de resultados previamente determinados. As respostas, depois da tabuladas e calculadas suas frequências, foram transformadas em gráficos de colunas para fornecer uma visão clara da atual situação do programa em relação à sua implementação nos municípios. Analisando os resultados, obteve-se que, dos nove módulos do programa, quatro foram implementados com eficácia restrita nos municípios, necessitando de ajustes em suas ações operacionais, por parte dos municípios; outros quatro módulos alcançaram resultados mais modestos quanto à sua implementação, demandando melhor acompanhamento e correções por conta dos gestores de turismo; e um módulo teve resultado ineficaz, pois foi implementado em apenas sete municípios, este sim, merecendo maior atenção na sua estruturação, nos seus objetivos, competências delegadas e estratégias. Confrontando esses resultados com a revisão teórica aqui levantada, verificou-se que o processo descentralizador aflorou a fragilidade dos municípios que não cumprem com suas atribuições previstas no programa; evidenciou-se uma fraca integração entre municípios e entre setores público/privado, no sentido de formarem ¿redes¿ de relacionamento e mostrou que o principal programa público de turismo do Brasil está carente de monitoramento e avaliação.