Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia. Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered. Results: Replacing oral typicals with risperidone or olanzapine has an incremental cost-effectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least cost-effective intervention is to replace risperidone with olanzapine at A$160 000/DALY. Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

A systematic review of topical skin care in aged care facilities

This systematic review aimed to evaluate the best available evidence regarding the effectiveness of topical skin care interventions for residents of aged care facilities. Introduction. Natural changes to skin, as well as increased predisposition to pressure sores and incontinence, means residents of aged care facilities readily require topical skin care. A range of interventions exist that aim to maintain or improve the integrity of skin of older adults. Methods. Pubmed, Embase, Current Contents, CINAHL and The Cochrane Library databases were searched, as well as Health Technology Assessment websites up to April 2003. Systematic reviews and randomized or non-randomized controlled trials were evaluated for quality and data were independently extracted by two reviewers. Results. The effectiveness of topical skin interventions was variable and dependent on the skin condition being treated. Studies examined the effectiveness of washing products on incontinence irritated skin. Disposable bodyworns may prevent deterioration of skin condition better than non-disposable underpads or bodyworns. Clinisan, a no-rinse cleanser may reduce the incidence of incontinence associated pressure ulcers when compared with soap and water. Conclusion. In general the quality of evidence for interventions to improve or maintain the skin condition in the older person was poor and more research in this area is needed. Relevance to Clinical Practice. Skin care is a major issue for nurses working with older people. On the basis of this review no clear recommendations can be made. This lack of strong evidence for nurses to base effective practice decisions is problematic. However, the 'best' evidence suggests that disposable bodyworns are a good investment in the fight against skin deterioration. No rinse cleansers are to be preferred over soap and the use of the bag bath appears to be a useful practice to reduce the risk of dry skin ( a risk factor for breaches in skin integrity).

Retrieving designs from a sketch using an automated GT coding and classification system

While the retrieval of existing designs to prevent unnecessary duplication of parts is a recognised strategy in the control of design costs the available techniques to achieve this, even in product data management systems, are limited in performance or require large resources. A novel system has been developed based on a new version of an existing coding system (CAMAC) that allows automatic coding of engineering drawings and their subsequent retrieval using a drawing of the desired component as the input. The ability to find designs using a detail drawing rather than textual descriptions is a significant achievement in itself. Previous testing of the system has demonstrated this capability but if a means could be found to find parts from a simple sketch then its practical application would be much more effective. This paper describes the development and testing of such a search capability using a database of over 3000 engineering components.

Lead time reduction for new products

The research, which was given the terms of reference, "To cut the lead time for getting new products into volume production", was sponsored by a company which develops and manufactures telecommunications equipment. The research described was based on studies made of the development of two processors which were designed to control telephone exchanges in the public network. It was shown that for each of these products, which were large electronic systems containing both hardware and software, most of their lead time was taken up with development. About half of this time was consumed by activities associated with redesign resulting from changes found to be necessary after the original design had been built. Analysing the causes of design changes showed the most significant to be Design Faults. The reasons why these predominated were investigated by seeking the collective opinion from design staff and their management using a questionnaire. Using the results from these studies to build upon the works of other authors, a model of the development process of large hierarchical systems is derived. An important feature of this model is its representation of iterative loops due to design changes. In order to reduce the development time, two closely related philosophies are proposed: By spending more time at the early stages of development (detecting and remedying faults in the design) even greater savings can be made later on, The collective performance of the development organisation would be improved by increasing the amount and speed of feedback about that performance. A trial was performed to test these philosophies using readily available techniques for design verification. It showed that about an 11 per cent saving would be made on the development time and that the philosophies might be equally successfully applied to other products and techniques.

Collocation:applications and implications

All aspects of the concept of collocation – the phenomenon whereby words naturally tend to occur in the company of a restricted set of other words – are covered in this book. It deals in detail with the history of the word collocation, the concepts associated with it and its use in a linguistic context. The authors show the practical means by which the collocational behaviour of words can be explored using illustrative computer programs and examine applications in teaching, lexicography and natural language processing that use collocation in formation. The book investigates the place that collocation occupies in theories of language and provides a thoroughly comprehensive and up-to-date survey of the current position of collocation in language studies and applied linguistics. This text presents a comprehensive description of collocation, covering both the theoretical and practical background and the implications and applications of the concept as language model and analytical tool. It provides a definitive survey of currently available techniques and a detailed description of their implementation.

Experiences of patients with age-related macular degeneration receiving anti-vascular endothelial growth factor therapy:a qualitative study

The societal cost for the average health authority in the United Kingdom for the care of wet age-related macular degeneration (AMD) has been suggested to be around £7.4 million. It is vital that the best possible care based on the best available evidence is provided to reduce the impact of AMD on patients' lives and the financial cost to the health-care system. This study explored the experiences of AMD patients treated with intravitreal ranibizumab injections. Three semistructured interviews were conducted with seven participants over the course of 18 months. Transcripts were analysed using interpretative phenomenological analysis. Analysis identified four themes: preparing for treatment, the treatment process, patient-provider communication, and results of treatment. Patient experiences highlighted the need to move away from the reliance on letters for information provision, and the need for clearer guidelines about when to cease AMD treatment. Interviews highlighted the need for the inclusion of rigorous qualitative evidence with experiential data in future good clinical practice guideline development for AMD. © The Author(s) 2013.

Dynamic decision-making based on NFR for managing software variability and configuration selection

Due to dynamic variability, identifying the specific conditions under which non-functional requirements (NFRs) are satisfied may be only possible at runtime. Therefore, it is necessary to consider the dynamic treatment of relevant information during the requirements specifications. The associated data can be gathered by monitoring the execution of the application and its underlying environment to support reasoning about how the current application configuration is fulfilling the established requirements. This paper presents a dynamic decision-making infrastructure to support both NFRs representation and monitoring, and to reason about the degree of satisfaction of NFRs during runtime. The infrastructure is composed of: (i) an extended feature model aligned with a domain-specific language for representing NFRs to be monitored at runtime; (ii) a monitoring infrastructure to continuously assess NFRs at runtime; and (iii) a exible decision-making process to select the best available configuration based on the satisfaction degree of the NRFs. The evaluation of the approach has shown that it is able to choose application configurations that well fit user NFRs based on runtime information. The evaluation also revealed that the proposed infrastructure provided consistent indicators regarding the best application configurations that fit user NFRs. Finally, a benefit of our approach is that it allows us to quantify the level of satisfaction with respect to NFRs specification.

Mangrove production and carbon sinks: A revision of global budget estimates

Mangrove forests are highly productive but globally threatened coastal ecosystems, whose role in the carbon budget of the coastal zone has long been debated. Here we provide a comprehensive synthesis of the available data on carbon fluxes in mangrove ecosystems. A reassessment of global mangrove primary production from the literature results in a conservative estimate of ∼218 ± 72 Tg C a−1. When using the best available estimates of various carbon sinks (organic carbon export, sediment burial, and mineralization), it appears that >50% of the carbon fixed by mangrove vegetation is unaccounted for. This unaccounted carbon sink is conservatively estimated at ∼112 ± 85 Tg C a−1, equivalent in magnitude to ∼30–40% of the global riverine organic carbon input to the coastal zone. Our analysis suggests that mineralization is severely underestimated, and that the majority of carbon export from mangroves to adjacent waters occurs as dissolved inorganic carbon (DIC). CO2 efflux from sediments and creek waters and tidal export of DIC appear to be the major sinks. These processes are quantitatively comparable in magnitude to the unaccounted carbon sink in current budgets, but are not yet adequately constrained with the limited published data available so far.

Seagrass sediments as a global carbon sink: Isotopic constraints

Seagrass meadows are highly productive habitats found along many of the world's coastline, providing important services that support the overall functioning of the coastal zone. The organic carbon that accumulates in seagrass meadows is derived not only from seagrass production but from the trapping of other particles, as the seagrass canopies facilitate sedimentation and reduce resuspension. Here we provide a comprehensive synthesis of the available data to obtain a better understanding of the relative contribution of seagrass and other possible sources of organic matter that accumulate in the sediments of seagrass meadows. The data set includes 219 paired analyses of the carbon isotopic composition of seagrass leaves and sediments from 207 seagrass sites at 88 locations worldwide. Using a three source mixing model and literature values for putative sources, we calculate that the average proportional contribution of seagrass to the surface sediment organic carbon pool is ∼50%. When using the best available estimates of carbon burial rates in seagrass meadows, our data indicate that between 41 and 66 gC m−2 yr−1 originates from seagrass production. Using our global average for allochthonous carbon trapped in seagrass sediments together with a recent estimate of global average net community production, we estimate that carbon burial in seagrass meadows is between 48 and 112 Tg yr−1, showing that seagrass meadows are natural hot spots for carbon sequestration.

Estimating Global “Blue Carbon” Emissions from Conversion and Degradation of Vegetated Coastal Ecosystems

Recent attention has focused on the high rates of annual carbon sequestration in vegetated coastal ecosystems—marshes, mangroves, and seagrasses—that may be lost with habitat destruction (‘conversion’). Relatively unappreciated, however, is that conversion of these coastal ecosystems also impacts very large pools of previously-sequestered carbon. Residing mostly in sediments, this ‘blue carbon’ can be released to the atmosphere when these ecosystems are converted or degraded. Here we provide the first global estimates of this impact and evaluate its economic implications. Combining the best available data on global area, land-use conversion rates, and near-surface carbon stocks in each of the three ecosystems, using an uncertainty-propagation approach, we estimate that 0.15–1.02 Pg (billion tons) of carbon dioxide are being released annually, several times higher than previous estimates that account only for lost sequestration. These emissions are equivalent to 3–19% of those from deforestation globally, and result in economic damages of $US 6–42 billion annually. The largest sources of uncertainty in these estimates stems from limited certitude in global area and rates of land-use conversion, but research is also needed on the fates of ecosystem carbon upon conversion. Currently, carbon emissions from the conversion of vegetated coastal ecosystems are not included in emissions accounting or carbon market protocols, but this analysis suggests they may be disproportionally important to both. Although the relevant science supporting these initial estimates will need to be refined in coming years, it is clear that policies encouraging the sustainable management of coastal ecosystems could significantly reduce carbon emissions from the land-use sector, in addition to sustaining the well-recognized ecosystem services of coastal habitats.

Caring for the autistic child: a resource manual for health care providers

Background: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that affects approximately 1 in 68 children (CDC, 2014). Comorbid medical conditions and psychiatric disorders increase the likelihood that these children will require acute care services more often than their neurotypical peers (McDermott, Zhou, & Mann, 2008; Simonoff et al., 2008). The evidence suggests that most health care providers are unprepared for the complexity of the interactions with these children during an acute care episode (McGongile, Migyanka, et al., 2014; McGongile, Venkat, et al., 2014; Muskat et al., 2015). Currently, there are no formalized training programs for acute health care workers in Regina Qu’Appelle Health Region (RQHR). Purpose: The purpose of this practicum project was to use the best available evidence on the care needs of children with Autism Spectrum Disorder (ASD) and effective interaction strategies to guide development of a resource manual for acute care health workers, especially registered nurses (RNs), working in the RQHR. Methods: Initial steps involved planning for and conducting a needs assessment. The resulting database emerged from a critical review of relevant literature, an environmental scan of resources within RQHR, and informal consultations with parents and caregivers of children with ASD, acute care nurses and nurse managers and experts in the field of ASD. Following analysis and collation of all data into major themes, a draft blueprint guided development of a resource manual for health care providers interacting with and providing care to children with ASD. Results: The needs assessment data informed development of an educational resource manual appropriate for all health care providers who encounter children with ASD and their parents and/or caregivers within acute care environments. The Caring for the Autistic Child: A Guide for Health Care Providers in Acute Care provides insightful information on the disorder and associated comorbid conditions, as well as effective approaches to care delivery with this priority population. Implementation and evaluation plans will guide distribution of the resource manual within the RQHR. Conclusion: The sequential and interdependent steps taken in this practicum project led to the development of a resource manual comprised of simple, easy to implement strategies capable of assisting nurses and all healthcare providers in providing care tailored to the autistic child’s unique needs and challenges.

(Table 1) Isotopic composition of organic compinents of DSDP Hole 24-231

Plant leaf wax hydrogen isotope (dDwax) reconstructions are increasingly being used to reconstruct hydrological change. This approach is based upon the assumption that variations in hydroclimatic variables, and in particular, the isotopic composition of precipitation (dDP), dominate dDwax. However modern calibration studies suggest that offsets between plant types may bias the dDwax hydrological proxy at times of vegetation change. In this study, I pair leaf wax analyses with published pollen data to quantify this effect and construct the first vegetation-corrected hydrogen isotopic evidence for precipitation (dDcorrP). In marine sediments from Deep Sea Drilling Program Site 231 in the Gulf of Aden spanning 11.4-3.8 Ma (late Miocene and earliest Pliocene), I find 77 per mil swings in dDwax that correspond to pollen evidence for substantial vegetation change. Similarities between dDP and dDcorrP imply that the hydrological tracer is qualitatively robust to vegetation change. However, computed vegetation corrections can be as large as 31 per mil indicating substantial quantitative uncertainty in the raw hydrological proxy. The resulting dDcorrP values quantify hydrological change and allow us to identify times considerably wetter than modern at 11.09, 7.26, 5.71 and 3.89 Ma. More generally, this novel interpretative framework builds the foundations of improved quantitative paleohydrological reconstructions with the dDwax proxy, in contexts where vegetation change may bias the plant-based proxy. The vegetation corrected paleoprecipitation reconstruction dDcorrP, represents the best available estimate as proof-of-concept, for an approach that I hope will be refined and more broadly applied.

Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many

The use of multiple medicines (polypharmacy) is increasingly common in middle-aged and older populations. Ensuring the correct balance between the prescribing of ‘many’ drugs and ‘too many’ drugs is a significant challenge. Clinicians are tasked with ensuring that patients receive the most appropriate combinations of medications based on the best available evidence, and that medication use is optimised according to patients’ clinical needs (appropriate polypharmacy). Historically, polypharmacy has been viewed negatively because of the associated medication safety risks, such as drug interactions and adverse drug events. More recently, polypharmacy has been identified as a risk factor for under-prescribing, such that patients do not receive necessary medications and this can also pose risks to patients’ safety and well-being. The negative connotations that have long been associated with the term polypharmacy could potentially be acting as a driving factor for under-prescribing, whereby clinicians are reluctant to prescribe necessary medicines for patients who are already receiving ‘many’ medicines. It is now recognised that the prescribing of ‘many’ medicines can be entirely appropriate in patients with several chronic conditions and that the risks of adverse drug events that have been associated with polypharmacy may be greatly reduced when patients’ clinical context is taken into consideration. In this article, we outline the current perspectives on polypharmacy and make the case for adopting the term ‘appropriate polypharmacy’ in differentiating between the prescribing of ‘many’ drugs and ‘too many’ drugs. We also outline the inherent challenges in doing so and provide recommendations for future clinical practice and research.

Psychosocial interventions for reducing the harmful effects of war and conflict-related violence on young children aged 0-11 years (Protocol)

Children living in a conflict-affected society can be exposed to daily violence in their communities and, as such, may be at risk of a range of harmful effects. Psychosocial interventions in conflict-affected areas aim to improve outcomes for children and can be treatment or prevention focused. The literature mainly focuses on psychological effects e.g. PTSD or anxiety disorders. Until recently, rather less attention was paid to the influence of mediating variables (cultural context or personal capacity) and their importance in reducing harmful effects.

This systematic review will assess the effectiveness of interventions in reducing the harmful effects of war and conflict-related violence on young children. It will also determine whether the interventions have differential effects depending on age and gender.

Children living in conflict-affected societies have unique needs for support and services. As such, any intervention delivered should be designed and implemented using the best available evidence. Professionals, policy makers and service provider will benefit from this review as to ‘what works’ for this vulnerable population and further exploration (via a Ph.D.) is planned to further extend the impact of this review.

A Strategy for Maternity Care in Northern Ireland 2012-2018

DHSSPS has carried out a review of policy on maternity service provision in Northern Ireland. The review focused on the best available evidence for the care and treatment of mothers-to-be; quality, safety and service sustainability; wider workforce issues; and professional roles and responsibilities. As a result, a draft strategy was developed, which was the subject of a public consultation from 28 September 2011 to 23 January 2012. Following an analysis of the responses to the consultation, the final strategy, A Strategy for Maternity Care in Northern Ireland 2012-2018, was published on 2 July 2012. The Strategy is outcomes focused. The six outcomes are:- give every baby and family the best start in life; effective communication and high-quality maternity care; healthier women at the start of pregnancy (preconception care); effective, locally accessible, antenatal care and a positive experience for prospective parents; safe labour and birth (intrapartum) care with improved experiences for mothers and babies; and appropriate advice, and support for parents and baby after birth The strategy aims to provide women and their partners, HSC staff, commissioners and policy makers with a clear pathway for maternity care in Northern Ireland from pre conceptual care through to postnatal care. Within the document, twenty two objectives have been identified which link to the six outcomes identified above. The HSC Board and Public Health Agency will co-lead on implementation. An action plan will be developed to take account of the outcomes and objectives listed in the document. The Department will receive an annual report on progress towards implementation.