Cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with previous acute coronary syndromes aged 65 to 74 years compared with younger patients: Results from the LIPID study

Background We compared cost-effectiveness of pravastatin in a placebo-controlled trial in 5500 younger (31-64 years) and 3514 older patients (65-74 years) with previous acute coronary syndromes. Methods Hospitalizations and long-term medication within the 6 years of the trial were estimated in all patients. Drug dosage, nursing home, and ambulatory care costs were estimated from substudies. Incremental costs per life saved of pravastatin relative to placebo were estimated from treatment effects and resource use. Results Over 6 years, pravastatin reduced all-cause mortality by 4.3% in the older patients and by 2.3% in the younger patients. Older patients assigned pravastatin had marginally lower cost of pravastatin and other medication over 6 years (A$4442 vs A$4637), but greater cost offsets (A$2061 vs. A$897) from lower rates of hospitalizations. The incremental cost per life saved with pravastatin was A$55500 in the old and A$167200 in the young. Assuming no treatment effect beyond the study period, the life expectancy to age 82 years of additional survivors was 9.1 years in the older and. 17.3 years in the younger. Estimated additional life-years saved from pravastatin therapy were 0.39 years for older and 0.40 years for younger patients. Incremental costs per life-year saved were A$7581 in the older and A$1.4944 in the younger, if discounted at 5% per annum. Conclusions Pravastatin therapy was more cost-effective among older than younger patients, because of their higher baseline risk and greater cost offsets, despite their shorter life expectancy.

An n-of-1 trial service in clinical practice: Testing the effectiveness of stimulants for attention-deficit/hyperactivity disorder

OBJECTIVE. We sought to describe the clinical use of n-of-1 trials for attention-deficit/hyperactivity disorder in publicly and privately funded family and specialized pediatric practice in Australia. METHODS. We used a within-patient randomized, double-blind, crossover comparison of stimulant (dexamphetamine or methylphenidate) versus placebo or alternative stimulant using 3 pairs of treatment periods. Trials were conducted from a central location using mail and telephone communication, with local supervision by the patients' clinicians. PATIENTS. Our study population included children with clinically diagnosed attention-deficit/ hyperactivity disorder who were aged 5 to 16 years and previously stabilized on an optimal dose of stimulant. They were selected because treatment effectiveness was uncertain. MAIN OUTCOME MEASURES. Our measures included number of patients recruited, number of doctors who used the service, geographic spread, completion rates, response rate, and post-n-of-1 trial decisions. RESULTS. Forty-five doctors across Australia requested 108 n-of-1 trials, of which 86 were completed. In 69 drug-versus-placebo comparisons, 29 children responded better to stimulant than placebo. Immediately posttrial, 19 of 25 drug-versus-placebo responders stayed on the same stimulant, and 13 of 24 nonresponders ceased or switched stimulants. In 40 of 63 for which data were available, posttrial management was consistent with the trial results. For all types of n-of-1 trials, management changed for 28 of 64 children for whom information was available. DISCUSSION. Attention-deficit/hyperactivity disorder n-of-1 trials can be implemented successfully by mail and telephone communication. This type of trial can be valuable in clarifying treatment effect when it is uncertain, and in this series, they had a noticeable impact on short-term management.

Double-blind, placebo-controlled, randomized study of eicosapentaenoic acid diester in patients with cancer cachexia

Purpose: Eicosapentaenoic acid (EPA) has been proposed to have specific anticachectic effects. This trial compared EPA diethyl ester with placebo in cachectic cancer patients for effects on weight and lean body mass. Patients and Methods: Five hundred eighteen weight-losing patients with advanced gastrointestinal or lung cancer were studied in a multicenter, double-blind, placebo controlled trial. Patients were randomly assigned to receive a novel preparation of pure EPA at a dose of 2 g or 4 g daily or placebo (2g EPA, n = 175; 4 g EPA, n = 172; placebo, n = 171). Patients were assessed at 4 weeks and 8 weeks. Results: The groups were well balanced at baseline. Mean weight loss at baseline was 18% (n = 518). Over the 8-week treatment period, both intention-to-treat analysis and per protocol analysis revealed no statistically significant improvements in survival, weight, or other nutritional variables. There was, however, a trend in favor of EPA with analysis of the primary end point, weight, at 8 weeks showing a borderline, nonsignificant treatment effect (P = .066). Relative to placebo, mean weight increased by 1.2 kg with 2 g EPA (95% CI, 0 kg to 2.3 kg) and by 0.3 kg with 4g EPA (-0.9 kg to 1.5 kg). Conclusion: The results indicate no statistically significant benefit from single agent EPA in the treatment of cancer cachexia. Future studies should concentrate on other agents or combination regimens. © 2006 by American Society of Clinical Oncology.

Content-based VLE designs improve learning efficiency in constructivist statistics education

Background: We introduced a series of computer-supported workshops in our undergraduate statistics courses, in the hope that it would help students to gain a deeper understanding of statistical concepts. This raised questions about the appropriate design of the Virtual Learning Environment (VLE) in which such an approach had to be implemented. Therefore, we investigated two competing software design models for VLEs. In the first system, all learning features were a function of the classical VLE. The second system was designed from the perspective that learning features should be a function of the course's core content (statistical analyses), which required us to develop a specific-purpose Statistical Learning Environment (SLE) based on Reproducible Computing and newly developed Peer Review (PR) technology. Objectives: The main research question is whether the second VLE design improved learning efficiency as compared to the standard type of VLE design that is commonly used in education. As a secondary objective we provide empirical evidence about the usefulness of PR as a constructivist learning activity which supports non-rote learning. Finally, this paper illustrates that it is possible to introduce a constructivist learning approach in large student populations, based on adequately designed educational technology, without subsuming educational content to technological convenience. Methods: Both VLE systems were tested within a two-year quasi-experiment based on a Reliable Nonequivalent Group Design. This approach allowed us to draw valid conclusions about the treatment effect of the changed VLE design, even though the systems were implemented in successive years. The methodological aspects about the experiment's internal validity are explained extensively. Results: The effect of the design change is shown to have substantially increased the efficiency of constructivist, computer-assisted learning activities for all cohorts of the student population under investigation. The findings demonstrate that a content-based design outperforms the traditional VLE-based design. © 2011 Wessa et al.

Effectiveness of nonpharmacologic treatments for acute seasonal allergic conjunctivitis

Objective - To investigate whether artificial tears and cold compress alone or in combination provide a treatment benefit and whether they were as effective as or could enhance topical antiallergic medication. Design - Randomized, masked clinical trial. Participants - Eighteen subjects (mean age, 29.5±11.0 years) allergic to grass pollen. Intervention - Controlled exposure to grass pollen using an environmental chamber to stimulate an ocular allergic reaction followed by application of artificial tears (ATs), 5 minutes of cold compress (CC), ATs combined with CC, or no treatment applied at each separate visit in random order. A subset of 11 subjects also had epinastine hydrochloride (EH) applied alone and combined with CC in random order or instillation of a volume-matched saline control. Main Outcome Measures - Bulbar conjunctival hyperemia, ocular surface temperature, and ocular symptoms repeated before and every 10 minutes after treatment for 1 hour. Results - Bulbar conjunctival hyperemia and ocular symptoms decreased and temperature recovered to baseline faster with nonpharmaceutical treatments compared with no treatment (P?treatments (P?treatment effect of EH was enhanced by combining it with a CC (P?effect (P?>?0.05). At all measurement intervals, symptoms were reduced for both EH and EH combined with CC than CC or ATs alone or in combination (P?treatment showed a therapeutic effect on the signs and symptoms of allergic conjunctivitis. A CC enhanced the use of EH alone and was the only treatment to reduce symptoms to baseline within 1 hour of antigenic challenge. Signs of allergic conjunctivitis generally were reduced most by a combination of a CC in combination with ATs or EH.

Effectiveness of nonpharmacologic treatments for acute seasonal allergic conjunctivitis

Objective To investigate whether artificial tears and cold compress alone or in combination provide a treatment benefit and whether they were as effective as or could enhance topical antiallergic medication. Design Randomized, masked clinical trial. Participants Eighteen subjects (mean age, 29.5±11.0 years) allergic to grass pollen. Intervention Controlled exposure to grass pollen using an environmental chamber to stimulate an ocular allergic reaction followed by application of artificial tears (ATs), 5 minutes of cold compress (CC), ATs combined with CC, or no treatment applied at each separate visit in random order. A subset of 11 subjects also had epinastine hydrochloride (EH) applied alone and combined with CC in random order or instillation of a volume-matched saline control. Main Outcome Measures Bulbar conjunctival hyperemia, ocular surface temperature, and ocular symptoms repeated before and every 10 minutes after treatment for 1 hour. Results Bulbar conjunctival hyperemia and ocular symptoms decreased and temperature recovered to baseline faster with nonpharmaceutical treatments compared with no treatment (P <0.05). Artificial tears combined with CC reduced hyperemia more than other treatments (P <0.05). The treatment effect of EH was enhanced by combining it with a CC (P <0.001). Cold compress combined with ATs or EH lowered the antigen-raised ocular surface temperature to less than the pre-exposure baseline. Artificial tear instillation alone or CC combined with ATs or EH significantly reduced the temperature (P <0.05). Cold compress combined with ATs or EH had a similar cooling effect (P > 0.05). At all measurement intervals, symptoms were reduced for both EH and EH combined with CC than CC or ATs alone or in combination (P <0.014). Conclusions After controlled exposure to grass pollen, CC and AT treatment showed a therapeutic effect on the signs and symptoms of allergic conjunctivitis. A CC enhanced the use of EH alone and was the only treatment to reduce symptoms to baseline within 1 hour of antigenic challenge. Signs of allergic conjunctivitis generally were reduced most by a combination of a CC in combination with ATs or EH. © 2014 by the American Academy of Ophthalmology.

Auditory training and adult rehabilitation:a critical review of the evidence

Auditory Training (AT) describes a regimen of varied listening exercises designed to improve an individual’s ability to perceive speech. The theory of AT is based on brain plasticity (the capacity of neurones in the central auditory system to alter their structure and function) in response to auditory stimulation. The practice of repeatedly listening to the speech sounds included in AT exercises is believed to drive the development of more efficient neuronal pathways, thereby improving auditory processing and speech discrimination. This critical review aims to assess whether auditory training can improve speech discrimination in adults with mild-moderate SNHL. The majority of patients attending Audiology services are adults with presbyacusis and it is therefore important to evaluate evidence of any treatment effect of AT in aural rehabilitation. Ideally this review would seek to appraise evidence of neurophysiological effects of AT so as to verify whether it does induce change in the CAS. However, due to the absence of such studies on this particular patient group, the outcome measure of speech discrimination, as a behavioural indicator of treatment effect is used instead. A review of available research was used to inform an argument for or against using AT in rehabilitative clinical practice. Six studies were identified and although the preliminary evidence indicates an improvement gained from a range of AT paradigms, the treatment effect size was modest and there remains a lack of large-sample RCTs. Future investigation into the efficacy of AT needs to employ neurophysiological studies using auditory evoked potentials in hearing-impaired adults in order to explore effects of AT on the CAS.

Ecological effects of low-level phosphorus additions on two plant communities in a neotropical freshwater wetland ecosystem

We conducted a low-level phosphorus (P) enrichment study in two oligotrophic freshwater wetland communities (wet prairies [WP] and sawgrass marsh [SAW]) of the neotropical Florida Everglades. The experiment included three P addition levels (0, 3.33, and 33.3 mg P m−2 month−1), added over 2 years, and used in situ mesocosms located in northeastern Everglades National Park, Fla., USA. The calcareous periphyton mat in both communities degraded quickly and was replaced by green algae. In the WP community, we observed significant increases in net aboveground primary production (NAPP) and belowground biomass. Aboveground live standing crop (ALSC) did not show a treatment effect, though, because stem turnover rates of Eleocharis spp., the dominant emergent macrophyte in this community, increased significantly. Eleocharis spp. leaf tissue P content decreased with P additions, causing higher C:P and N:P ratios in enriched versus unenriched plots. In the SAW community, NAPP, ALSC, and belowground biomass all increased significantly in response to P additions. Cladium jamaicense leaf turnover rates and tissue nutrient content did not show treatment effects. The two oligotrophic communities responded differentially to P enrichment. Periphyton which was more abundant in the WP community, appeared to act as a P buffer that delayed the response of other ecosystem components until after the periphyton mat had disappeared. Periphyton played a smaller role in controlling ecosystem dynamics and community structure in the SAW community. Our data suggested a reduced reliance on internal stores of P by emergent macrophytes in the WP that were exposed to P enrichment. Eleocharis spp. rapidly recycled P through more rapid aboveground turnover. In contrast, C. jamaicense stored added P by initially investing in belowground biomass, then shifting growth allocation to aboveground tissue without increasing leaf turnover rates. Our results suggest that calcareous wetland systems throughout the Caribbean, and oligotrophic ecosystems in general, respond rapidly to low-level additions of their limiting nutrient.

Three Essays on Extremal Quantiles

Extremal quantile index is a concept that the quantile index will drift to zero (or one)

as the sample size increases. The three chapters of my dissertation consists of three

applications of this concept in three distinct econometric problems. In Chapter 2, I

use the concept of extremal quantile index to derive new asymptotic properties and

inference method for quantile treatment effect estimators when the quantile index

of interest is close to zero. In Chapter 3, I rely on the concept of extremal quantile

index to achieve identification at infinity of the sample selection models and propose

a new inference method. Last, in Chapter 4, I use the concept of extremal quantile

index to define an asymptotic trimming scheme which can be used to control the

convergence rate of the estimator of the intercept of binary response models.

Essays on Microeconometrics

My dissertation has three chapters which develop and apply microeconometric tech- niques to empirically relevant problems. All the chapters examines the robustness issues (e.g., measurement error and model misspecification) in the econometric anal- ysis. The first chapter studies the identifying power of an instrumental variable in the nonparametric heterogeneous treatment effect framework when a binary treat- ment variable is mismeasured and endogenous. I characterize the sharp identified set for the local average treatment effect under the following two assumptions: (1) the exclusion restriction of an instrument and (2) deterministic monotonicity of the true treatment variable in the instrument. The identification strategy allows for general measurement error. Notably, (i) the measurement error is nonclassical, (ii) it can be endogenous, and (iii) no assumptions are imposed on the marginal distribution of the measurement error, so that I do not need to assume the accuracy of the measure- ment. Based on the partial identification result, I provide a consistent confidence interval for the local average treatment effect with uniformly valid size control. I also show that the identification strategy can incorporate repeated measurements to narrow the identified set, even if the repeated measurements themselves are endoge- nous. Using the the National Longitudinal Study of the High School Class of 1972, I demonstrate that my new methodology can produce nontrivial bounds for the return to college attendance when attendance is mismeasured and endogenous.

The second chapter, which is a part of a coauthored project with Federico Bugni, considers the problem of inference in dynamic discrete choice problems when the structural model is locally misspecified. We consider two popular classes of estimators for dynamic discrete choice models: K-step maximum likelihood estimators (K-ML) and K-step minimum distance estimators (K-MD), where K denotes the number of policy iterations employed in the estimation problem. These estimator classes include popular estimators such as Rust (1987)’s nested fixed point estimator, Hotz and Miller (1993)’s conditional choice probability estimator, Aguirregabiria and Mira (2002)’s nested algorithm estimator, and Pesendorfer and Schmidt-Dengler (2008)’s least squares estimator. We derive and compare the asymptotic distributions of K- ML and K-MD estimators when the model is arbitrarily locally misspecified and we obtain three main results. In the absence of misspecification, Aguirregabiria and Mira (2002) show that all K-ML estimators are asymptotically equivalent regardless of the choice of K. Our first result shows that this finding extends to a locally misspecified model, regardless of the degree of local misspecification. As a second result, we show that an analogous result holds for all K-MD estimators, i.e., all K- MD estimator are asymptotically equivalent regardless of the choice of K. Our third and final result is to compare K-MD and K-ML estimators in terms of asymptotic mean squared error. Under local misspecification, the optimally weighted K-MD estimator depends on the unknown asymptotic bias and is no longer feasible. In turn, feasible K-MD estimators could have an asymptotic mean squared error that is higher or lower than that of the K-ML estimators. To demonstrate the relevance of our asymptotic analysis, we illustrate our findings using in a simulation exercise based on a misspecified version of Rust (1987) bus engine problem.

The last chapter investigates the causal effect of the Omnibus Budget Reconcil- iation Act of 1993, which caused the biggest change to the EITC in its history, on unemployment and labor force participation among single mothers. Unemployment and labor force participation are difficult to define for a few reasons, for example, be- cause of marginally attached workers. Instead of searching for the unique definition for each of these two concepts, this chapter bounds unemployment and labor force participation by observable variables and, as a result, considers various competing definitions of these two concepts simultaneously. This bounding strategy leads to partial identification of the treatment effect. The inference results depend on the construction of the bounds, but they imply positive effect on labor force participa- tion and negligible effect on unemployment. The results imply that the difference- in-difference result based on the BLS definition of unemployment can be misleading

due to misclassification of unemployment.

Group problem-solving skills training for self-harm: randomised controlled trial

Background: Rates of self-harm are high and have recently increased. This trend and the repetitive nature of self-harm pose a significant challenge to mental health services. Aims: To determine the efficacy of a structured group problem-solving skills training (PST) programme as an intervention approach for self-harm in addition to treatment as usual (TAU) as offered by mental health services. Method: A total of 433 participants (aged 18-64 years) were randomly assigned to TAU plus PST or TAU alone. Assessments were carried out at baseline and at 6-week and 6-month follow-up and repeated hospital-treated self-harm was ascertained at 12-month follow-up. Results: The treatment groups did not differ in rates of repeated self-harm at 6-week, 6-month and 12-month follow-up. Both treatment groups showed significant improvements in psychological and social functioning at follow-up. Only one measure (needing and receiving practical help from those closest to them) showed a positive treatment effect at 6-week (P = 0.004) and 6-month (P = 0.01) follow-up. Repetition was not associated with waiting time in the PST group. Conclusions: This brief intervention for self-harm is no more effective than treatment as usual. Further work is required to establish whether a modified, more intensive programme delivered sooner after the index episode would be effective.

Stepped Wedge Design for Multiple Interventions

Thesis (Master's)--University of Washington, 2016-08

Economic Evaluations of State Policies

Thesis (Ph.D.)--University of Washington, 2016-08

Fumonisina B1 em arroz: validação de método e efeito de tratamento térmico nos níveis da micotoxina

O arroz (Oryza sativa, L.), como todos os cereais, pode ser contaminado por fungos responsáveis por danos tecnológicos, nutricionais e toxicológicos, dentre eles a produção de micotoxinas. Diversas toxinas fúngicas produzidas pelo gênero Fusarium tem sido relatadas em arroz, no entanto a fumonisina B1 (FB1) é pouco estudada neste grão. As principais características da FB1 é a alta solubilidade em solventes polares, estabilidade a altas temperaturas além de efeitos neurotóxicos e carcinogênicos. Assim o objetivo deste trabalho foi avaliar o efeito do tratamento térmico e hidrotérmico nos teores de fumonisina B1 e nas características químicas de arroz comercial. Na primeira etapa do trabalho foi adaptado um método para detecção e quantificação de FB1 em arroz cru e após cocção, por HPLC-FL. O método foi avaliado quanto aos indicativos de eficiência destacando-se o LOD (30 µg.kg-1) e a recuperação ( 90% para arroz cru e 86% pra arroz cozido). Na segunda etapa realizou-se o levantamento de ocorrência de FB1 em 05 diferentes amostras comerciais de arroz integral, branco e parboilizado da cidade de Rio Grande, RS, totalizando 9 amostras. Foi detectada a presença de FB1 em 7 das 9 amostras, sendo que os maiores índices foram encontrados em amostras de arroz parboilizado e integral apresentando níveis de contaminação entre 30 e 170 µg.kg-1. A terceira etapa do trabalho consistiu no estudo do efeito de tratamentos térmicos sobre os níveis de FB1 em amostras após aplicação de calor. Foram testados tratamento hidrotérmico com evaporação, tratamento hidrotérmico com autoclavagem e tratamento térmico seco. O maior nível de redução dos teores iniciais de FB1 foi 82,8% quando se empregou tratamento térmico seco a 125 °C/3 min. Ainda foram avaliados os efeitos do t ratamento hidrotérmico com evaporação de água na composição química e na digestibilidade protéica. Esta característica proporcionou aumento de até 100% na digestibilidade in vitro das proteínas e reduziu em média 73% do teor de contaminação com FB1.

Influence of levels and forms of selenium associated with levels of vitamins C and E on the performance, yield and composition of tilapia fillet

Objetivou-se avaliar a influência da vitamina C (VC), vitamina E (VE) e de duas formas de selênio sobre o desempenho, rendimento e qualidade do filé de tilápia Nilótica. O experimento foi realizado num delineamento inteiramente casualizado composto por seis tratamentos, os quais foram constituídos pela adição de 100, 200 e 400 mg kg-1 das vitaminas C e E, associados com 0,1, 0,2 e 0,4 mg kg-1 de duas formas de selênio. Cada tratamento foi constituído por cinco repetições de 30 peixes cada. A dieta com 200 mg kg-1 de VC e VE + 0,2 mg kg-1 de selênio orgânico proporcionou ganho de peso, comprimento corporal e fator de conversão alimentar semelhantes aos tratamentos com 400 mg kg-1 de VC e VE + 0,4 mg kg-1 de selênio orgânico ou inorgânico. A adição de selênio orgânico à dieta melhorou o ganho de peso e o fator de conversão alimentar em comparação com o selênio inorgânico. A dieta com 0,2 mg kg-1 de selênio orgânico apresentou nível de glutationa peroxidase igual ao da dieta com 0,4 mg kg-1 de selênio inorgânico. Os rendimentos de carcaça e filé não foram influenciados pelos tratamentos, entretanto houve efeito dos tratamentos na composição química do filé.