Routine Measurement of Health-Related Quality of Life in Assessing Cost-Effectiveness in Secondary Health Care

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.

Amber teething necklaces – medical marvel or maternal myth?

BACKGROUND: Baltic amber-bead necklaces or bracelets are commonly used for managing teething symptoms in infants. The effectiveness of these beads is claimed to be from succinic acid release (a compound with analgesic and anti-inflammatory properties), which is then absorbed through the skin. AIM: To investigate whether Baltic amber teething necklaces purchased in Australia contained succinic acid, and to quantify succinic acid release from the beads. METHODS: Infrared spectroscopy was used to confirm that the teething necklaces were made of Baltic amber. The amount of succinic acid contained within the beads was quantified, and succinic acid release from intact beads was measured in phosphate buffered saline (PBS) pH 5.5 or octanol to simulate aqueous or oily skin environments. RESULTS: Each necklace (33 beads in length) contained 19.17±4.89 mg of succinic acid (mean±se). Over a 6-month period, no succinic acid was detected in PBS, while 0.13±0.09 mg of succinic acid per necklace was released in octanol. Only one replicate of amber beads in octanol released succinic acid, and they had fragmented, with shards free-floating in the solvent. DISCUSSION: It is likely succinic acid was only detected because the beads were breaking down in octanol, which does not occur when worn around the neck of a child. Furthermore, the hydrophilic properties of succinic acid would not favour its absorption across hydrophobic layers of the skin and into the bloodstream. CONCLUSION: While the teething necklaces do contain small quantities of succinic acid, it is highly unlikely to be released from intact beads.

Thermal characterization of microheaters from the dynamic response

Thermal characterization of surface-micromachined microheaters is carried out from their dynamic response to electrothermal excitations. An electrical equivalent circuit model is developed for the thermo-mechanical system. The mechanical parameters are extracted from the frequency response obtained using a laser Doppler vibrometer. The resonant frequencies of the microheaters are measured and compared with FEM simulations. The thermal time constants are obtained from the electrical equivalent model by fitting the model response to the measured frequency response. Microheaters with an active area of 140 µm × 140 µm have been realized on two different layers (poly-1 and poly-2) with two different air gaps (2 µm and 2.75 µm). The effective time constants, combining thermal and mechanical responses, are in the range of 0.13–0.22 ms for heaters on the poly-1 layer and 1.9 µs–0.15 ms for microheaters on the poly-2 layer. The thermal time constants of the microheaters are in the range of a few microseconds, thus making them suitable for sensor applications that need a faster thermal response.

Sensing Shape Recovery Using Conductivity Noise in Thin Films of NiTi Shape Memory Alloys

Low frequency fluctuations in the electrical resistivity, or noise, have been used as a sensitive tool to probe into the temperature driven martensite transition in dc magnetron sputtered thin films of nickel titanium shape-memory alloys. Even in the equilibrium or static case, the noise magnitude was more than nine orders of magnitude larger than conventional metallic thin films and had a characteristic dependence on temperature. We observe that the noise while the temperature is being ramped is far larger as compared to the equilibrium noise indicating the sensitivity of electrical resistivity to the nucleation and propagation of domains during the shape recovery. Further, the higher order statistics suggests the existence of long range correlations during the transition. This new characterization is based on the kinetics of disorder in the system and separate from existing techniques and can be integrated to many device applications of shape memory alloys for in-situ shape recovery sensing.

Molecular Genetic Background of Tumours in Hereditary Leiomyomatosis and Renal Cell Cancer Syndrome

Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC) is a hereditary tumour predisposition syndrome. Its phenotype includes benign cutaneous and uterine leiomyomas (CLM, ULM) with high penetrance and rarer renal cell cancer (RCC), most commonly of papillary type 2 subtype. Over 130 HLRCC families have been identified world-wide but the RCC phenotype seems to concentrate in families from Finland and North America for unknown reasons. HLRCC is caused by heterozygous germline mutations in the fumarate hydratase (FH) gene. FH encodes the enzyme fumarase from mitochondrial citric acid cycle. Fumarase enzyme activity or type or site of the FH mutation are unassociated with disease phenotype. The strongest evidence for tumourigenesis mechanism in HLRCC supports a hypoxia inducible factor driven process called pseudohypoxia resulting from accumulation of the fumarase substrate fumarate. In this study, to assess the importance of gene- or exon-level deletions or amplifications of FH in patients with HLRCC-associated phenotypes, multiplex ligation-dependent probe amplification (MLPA) method was used. One novel FH mutation, deletion of exon 1, was found in a Swedish male patient with an evident HLRCC phenotype with CLM, RCC, and a family history of ULM and RCC. Six other patients with CLM and 12 patients with only RCC or uterine leiomyosarcoma (ULMS) remained FH mutation-negative. These results suggest that copy number aberrations of FH or its exons are an infrequent cause of HLRCC and that only co-occurrence of benign tumour types justifies FH-mutation screening in RCC or ULMS patients. Determination of the genomic profile of 11 HLRCC-associated RCCs from Finnish patients was performed by array comparative genomic hybridization. The most common copy number aberrations were gains of 2, 7, and 17 and losses of 13q12.3-q21.1, 14, 18, and X. When compared to aberrations of sporadic papillary RCCs, HLRCC-associated RCCs harboured a distinct DNA copy number profile and lacked many of the changes characterizing the sporadic RCCs. The findings suggest a divergent molecular pathway for tumourigenesis of papillary RCCs in HLRCC. In order to find a genetic modifier of RCC risk in HLRCC, genome-wide linkage and identical by descent (IBD) analysis studies were performed in Finnish HLRCC families with microsatellite marker mapping and SNP-array platforms. The linkage analysis identified only one locus of interest, the FH gene locus in 1q43, but no mutations were found in the genes of the region. IBD analysis yielded no convincing haplotypes shared by RCC patients. Although these results do not exclude the existence of a genetic modifier for RCC risk in HLRCC, they emphasize the role of FH mutations in the malignant tumourigenesis of HLRCC. To study the benign tumours in HLRCC, genome-wide DNA copy number and gene expression profiles of sporadic and HLRCC ULMs were defined with modern SNP- and gene-expression array platforms. The gene expression array suggests novel genes involved in FH-deficient ULM tumourigenesis and novel genes with putative roles in propagation of sporadic ULM. Both the gene expression and copy number profiles of HLRCC ULMs differed from those of sporadic ULMs indicating distinct molecular basis of the FH-deficient HLRCC tumours.

Proton Spin-Lattice Relaxation in Sodium Ammonium Selenate Dihydrate:NaNHaSeOa.2He0

Proton spin-lattice relaxation studies in sodium ammonium selenate dihydrate carried out in the temperature range 130 to 300 K at 10 MHz show a continuous change in T, at T, indicating a second order phase transition. This compound is a typical case of a highly hindered solid wherein the thermally activated reorientations of ammonium ions freeze well above 77 K, as seen by NMR.Untersuchimgen der Protonen-Spin-Gitter-Relaxation in Natriuni-Ammoniumselenat-Dihydrat bei 10 MHz im Temperaturbereich 130 bis 300 K zeigen eine kontinuierliche Andernng in TI bei T, und ergeben einen Phasenubergang zweiter Art. Diese Verbindung ist ein typischer Fall eines stark ,,behinderten" Festkarpers, in dein die thermisch aktivierten Reorientierungen der Ammoniumionen weit oberhalb 77 H einfrieren, wie die NMR-Ergebnisse zeigen.

Role of prolactin(prl) in regulation of the nocturnal surge of testosterone (t) in the bonnet monkey (macaca radiata)

Earlier studies from this lebordory have shown thet adult male bonnet monkeys exhibit nychthemrel rhythmicity la the secretion of serum 'T' the levele reehlng peek by 22OOhr. Of the gonedotropine cnelyeed only serum PRL showed a concommitent increme with T(Biol.of Reprod. 24,814, 1981). In the present study mMinietretion of l rgobromocryptin (EBC) either by i.v.route(2mg)or by naeel l pr~(100~)reeulted in blockade of nocturnal increase of both PRL end T(Controle T-18.6ng/ml: PRL 130=29ng/ml: EBC treated T-2.2&1.2ng/ml; PRL n.d.to 15nng/ml). Adminietretion of N oPRL could not reverse the effect of EBC. Although, increaeed serum PRL induced by injection of Chlorprommine did not result in increase in serum 'T' during the dey time, the nocturnel 'T' surge could not be obeeerved. EBC treeted monkeys, however, showed normal testosterone response to exogenous hCG. These IeSUlte a0 SwgeStive of high levels of PRL me&in6 reeponeiveneee of testes to tonic levels of serum IX. (Aided by grant8 from ICMR, Kew Delhi, WHO, Geneva eld FPF, India).

Thermo-chemical interpretation of polymer degradation

A correlation has been established between the heat of depolymerization (DeltaH) of vinyl polymers for going from solid polymer state to gaseous monomer state and the activation energy (E) of degradation. On this basis it has been shown that the rate controlling step in the degradation lies in the initiation step. Attempt has been made to correlate theE and DeltaH with glass transition temperature (Tg) and melting temperature (Tm) of the polymers.[/ p]

Multiple host use by a sap-sucking membracid: population consequences of nymphal development on primary and secondary host plant species

Aconophora compressa is a gregarious, sap-sucking insect that uses multiple host plant species. Nymphal host plant species (and variety) significantly affected nymphal survival, nymphal development rate and the subsequent size and fecundity of adults, with fiddlewood ( Citharexylum spinosum ) being significantly best in all respects. Nymphs that developed on a relatively poor host ( Duranta erecta var “geisha girl”) and which were moved to fiddlewood as adults laid significantly fewer eggs (mean ± SE = 836 ± 130) than those that developed solely on fiddlewood (1,329 ± 105). Adults on geisha girl, regardless of having been reared as nymphs on fiddlewood or geisha girl, laid significantly fewer eggs (342 ± 83 and 317 ± 74, respectively) than adults on fiddlewood. A simple model that incorporates host plant related survival, development rate and fecundity suggests that the population dynamics of A. compressa are governed mainly by fiddlewood, the primary host. The results have general implications for understanding the population dynamics of herbivores that use multiple host plant species, and also for the way in which weed biological control host testing methods should be conducted.

From a tree to a stand in Finnish boreal forests: biomass estimation and comparison of methods

There is an increasing need to compare the results obtained with different methods of estimation of tree biomass in order to reduce the uncertainty in the assessment of forest biomass carbon. In this study, tree biomass was investigated in a 30-year-old Scots pine (Pinus sylvestris) (Young-Stand) and a 130-year-old mixed Norway spruce (Picea abies)-Scots pine stand (Mature-Stand) located in southern Finland (61º50' N, 24º22' E). In particular, a comparison of the results of different estimation methods was conducted to assess the reliability and suitability of their applications. For the trees in Mature-Stand, annual stem biomass increment fluctuated following a sigmoid equation, and the fitting curves reached a maximum level (from about 1 kg/yr for understorey spruce to 7 kg/yr for dominant pine) when the trees were 100 years old. Tree biomass was estimated to be about 70 Mg/ha in Young-Stand and about 220 Mg/ha in Mature-Stand. In the region (58.00-62.13 ºN, 14-34 ºE, ≤ 300 m a.s.l.) surrounding the study stands, the tree biomass accumulation in Norway spruce and Scots pine stands followed a sigmoid equation with stand age, with a maximum of 230 Mg/ha at the age of 140 years. In Mature-Stand, lichen biomass on the trees was 1.63 Mg/ha with more than half of the biomass occurring on dead branches, and the standing crop of litter lichen on the ground was about 0.09 Mg/ha. There were substantial differences among the results estimated by different methods in the stands. These results imply that a possible estimation error should be taken into account when calculating tree biomass in a stand with an indirect approach.

Genomewide significant linkage to migrainous headache on chromosome 5q21

Familial typical migraine is a common, complex disorder that shows strong familial aggregation. Using latent-class analysis (LCA), we identified subgroups of people with migraine/severe headache in a community sample of 12,245 Australian twins (60% female), drawn from two cohorts of individuals aged 23-90 years who completed an interview based on International Headache Society criteria. We report results from genomewide linkage analyses involving 756 twin families containing a total of 790 independent sib pairs (130 affected concordant, 324 discordant, and 336 unaffected concordant for LCA-derived migraine). Quantitative-trait linkage analysis produced evidence of significant linkage on chromosome 5q21 and suggestive linkage on chromosomes 8, 10, and 13. In addition, we replicated previously reported typical-migraine susceptibility loci on chromosomes 6p12.2-p21.1 and 1q21-q23, the latter being within 3 cM of the rare autosomal dominant familial hemiplegic migraine gene (ATP1A2), a finding which potentially implicates ATP1A2 in familial typical migraine for the first time. Linkage analyses of individual migraine symptoms for our six most interesting chromosomes provide tantalizing hints of the phenotypic and genetic complexity of migraine. Specifically, the chromosome 1 locus is most associated with phonophobia; the chromosome 5 peak is predominantly associated with pulsating headache; the chromosome 6 locus is associated with activity-prohibiting headache and photophobia; the chromosome 8 locus is associated with nausea/vomiting and moderate/severe headache; the chromosome 10 peak is most associated with phonophobia and photophobia; and the chromosome 13 peak is completely due to association with photophobia. These results will prove to be invaluable in the design and analysis of future linkage and linkage disequilibrium studies of migraine.

Declining trends in annual catch rates of the tiger shark (Galeocerdo cuvier) in Queensland, Australia

Suitable long term species-specific catch rate and biological data are seldom available for large shark species, particularly where historical commercial logbook reporting has been poor. However, shark control programs can provide suitable data from gear that consistently fishes nearshore waters all year round. We present an analysis of the distribution of 4757 . Galeocerdo cuvier caught in surface nets and on drumlines across 9 of the 10 locations of the Queensland Shark Control Program (QSCP) between 1993 and 2010. Standardised catch rates showed a significant decline (p<. 0.0001) in southern Queensland locations for both gear types, which contrasts with studies at other locations where increases in tiger shark catch per unit effort (CPUE) have been reported. Significant temporal declines in the average size of tiger sharks occurred at four of the nine locations analysed (p<. 0.05), which may be indicative of fishing reducing abundance in these areas. Given the long term nature of shark control programs along the Australian east coast, effects on local abundance should have been evident many years ago, which suggests that factors other than the effects of shark control programs have also contributed to the decline. While reductions in catch rate are consistent with a decline in tiger shark abundance, this interpretation should be made with caution, as the inter-annual CPUE varies considerably at most locations. Nevertheless, the overall downward trend, particularly in southern Queensland, indicates that current fishing pressures on the species may be unsustainable. © 2012 Elsevier B.V.

A Method for Isolation of Protoplasts from Dermatophytes

A method has been developed to isolate protoplasts from dermatophytes using Novozym 234. A simple technique of flotation in MgSO, has been adapted to separate protoplasts from incubation mixture. Electron microscopic studies confirmed the absence of cell wall material on these protoplasts. The recovery of DNA from protoplasts was higher than from mycelia.

Carbon Capture and Productivity of Plantation Forests in North-eastern Australia

Approximately 130,000 ha of hardwood plantations have been established in north-eastern Australia in the last 15 years. As a result of poor taxa selection approximately 25,000 ha have failed due to drought, pest and disease or extreme weather events (drought and cyclones). Given the predicted impacts of climate change in north-eastern Australia (reduced rainfall, increased temperatures and an increase in extreme weather conditions, particularly drought, storms and cyclones), selection of the right taxa for plantation development is even more critical as the taxon planted needs to be able to perform well under the environments experienced at planting as well as those that may develop over in 30 years time as a result of changing climate.