Intensive versus standard dose statin therapy: the costs and benefits for patients with acute coronary syndrome

Introduction: Recent NICE guidance in England and Wales states that statin therapy for secondary CVD should "usually be initiated with a drug with a low acquisition cost (taking into account required daily dose and product price per dose)". Intensive dose statin therapy is more costly than standard dose, but offers additional benefits and may potentially be more cost effective for a sub-group of high risk patients. Objective: To determine if the strategy of treating ACS patients with intensive dose statin compared with standard dose statin can be considered to be cost effective and to what extent these results are influenced by the age of the patient at start of treatment. Methods: A Markov model was used to explore the costs and health outcomes associated with a lifetime of intensive dose (represented by 80mg atorvastatin) versus standard dose (represented by 20mg simvastatin) treatment for patients with acute coronary syndrome. Health states included unstable angina, MI, stroke, fatal CHD, fatal stroke, or non vascular death. The benefits associated with statin treatment were modelled by applying the relative risks from a meta-analysis of 4 large RCTs reporting clinical endpoints. Costs and utilities assigned to health states were derived from a review of published evidence. Results: Treatment with intensive dose statin therapy offers additional benefits over standard dose therapy. The cost offsets through avoided events are less than the associated treatment costs and result in a cost per QALY of around £24,000 for patients with ACS starting treatment at 60 years of age and falling to around £14,000 for patients starting treatment at 70 years. The key driver of cost effectiveness is the relative risk for mortality. Conclusions: This analysis suggests that intensive statin regimens (represented by atorvastatin 80mg/day) are cost effective compared with standard statin regimens (represented by simvastatin 20mg/day) for patients with ACS over the age of 60 years. A recent registry study reports a mean age of 70 years for ACS patients admitted to UK hospitals and hence this comparison applies to the great majority of ACS patients

Intensive versus standard dose statin therapy: the costs and benefits for patients with acute coronary syndrome

Introduction: Recent NICE guidance in England and Wales states that statin therapy for secondary CVD should "usually be initiated with a drug with a low acquisition cost (taking into account required daily dose and product price per dose)". Intensive dose statin therapy is more costly than standard dose, but offers additional benefits and may potentially be more cost effective for a sub-group of high risk patients. Objective: To determine if the strategy of treating ACS patients with intensive dose statin compared with standard dose statin can be considered to be cost effective and to what extent these results are influenced by the age of the patient at start of treatment. Methods: A Markov model was used to explore the costs and health outcomes associated with a lifetime of intensive dose (represented by 80mg atorvastatin) versus standard dose (represented by 20mg simvastatin) treatment for patients with acute coronary syndrome. Health states included unstable angina, MI, stroke, fatal CHD, fatal stroke, or non vascular death. The benefits associated with statin treatment were modelled by applying the relative risks from a meta-analysis of 4 large RCTs reporting clinical endpoints. Costs and utilities assigned to health states were derived from a review of published evidence. Results: Treatment with intensive dose statin therapy offers additional benefits over standard dose therapy. The cost offsets through avoided events are less than the associated treatment costs and result in a cost per QALY of around £24,000 for patients with ACS starting treatment at 60 years of age and falling to around £14,000 for patients starting treatment at 70 years. The key driver of cost effectiveness is the relative risk for mortality. Conclusions: This analysis suggests that intensive statin regimens (represented by atorvastatin 80mg/day) are cost effective compared with standard statin regimens (represented by simvastatin 20mg/day) for patients with ACS over the age of 60 years. A recent registry study reports a mean age of 70 years for ACS patients admitted to UK hospitals and hence this comparison applies to the great majority of ACS patients

Universal geometric approach to uncertainty, entropy and information

It is shown that for any ensemble, whether classical or quantum, continuous or discrete, there is only one measure of the "volume" of the ensemble that is compatible with several basic geometric postulates. This volume measure is thus a preferred and universal choice for characterising the inherent spread, dispersion, localisation, etc, of the ensemble. Remarkably, this unique "ensemble volume" is a simple function of the ensemble entropy, and hence provides a new geometric characterisation of the latter quantity. Applications include unified, volume-based derivations of the Holevo and Shannon bounds in quantum and classical information theory; a precise geometric interpretation of thermodynamic entropy for equilibrium ensembles; a geometric derivation of semi-classical uncertainty relations; a new means for defining classical and quantum localization for arbitrary evolution processes; a geometric interpretation of relative entropy; and a new proposed definition for the spot-size of an optical beam. Advantages of the ensemble volume over other measures of localization (root-mean-square deviation, Renyi entropies, and inverse participation ratio) are discussed.Comment: Latex, 38 pages + 2 figures; p(\alpha)->1/|T| in Eq. (72) [Eq. (A10) of published version

Use of cumulative mortality data in patients with acute myocardial infarction for early detection of variation in clinical practice: observational study

OBJECTIVES: Use of cumulative mortality adjusted for case mix in patients with acute myocardial infarction for early detection of variation in clinical practice. DESIGN: Observational study. SETTING: 20 hospitals across the former Yorkshire region. PARTICIPANTS: All 2153 consecutive patients with confirmed acute myocardial infarction identified during three months. MAIN OUTCOME MEASURES: Variable life­adjusted displays showing cumulative differences between observed and expected mortality of patients; expected mortality calculated from risk model based on admission characteristics of age, heart rate, and systolic blood pressure. RESULTS: The performance of two individual hospitals over three months was examined as an example. One, the smallest district hospital in the region, had a series of 30 consecutive patients but had five more deaths than predicted. The variable life­adjusted display showed minimal variation from that predicted for the first 15 patients followed by a run of unexpectedly high mortality. The second example was the main tertiary referral centre for the region, which admitted 188 consecutive patients. The display showed a period of apparently poor performance followed by substantial improvement, where the plot rose steadily from a cumulative net lives saved of - 4 to 7. These variations in patient outcome are unlikely to have been revealed during conventional audit practice. CONCLUSIONS: Variable life­adjusted display has been integrated into surgical care as a graphical display of risk­adjusted survival for individual surgeons or centres. In combination with a simple risk model, it may have a role in monitoring performance and outcome in patients with acute myocardial infarction

Soliton molecules in trapped vector Nonlinear Schrodinger systems

We study a new class of vector solitons in trapped Nonlinear Schrodinger systems modelling the dynamics of coupled light beams in GRIN Kerr media and atomic mixtures in Bose-Einstein condensates. These solitons exist for different spatial dimensions, their existence is studied by means of a systematic mathematical technique and the analysis is made for inhomogeneous media

Institutional Learning and Change: an introduction

Originally published by the International Service for National Agricultural Research as: Watts, J. R. Mackay, D. Horton, A. Hall, B. Douthwaite, R. Chambers and A. Acosta. (2003). Institutional learning and change: An introduction. ISNAR Discussion Paper No.03-10, The Hague: International Service for National Agricultural ResearchThroughout the world, the pace of environmental, social and technological change is accelerating, and this in turn has major implications for the poor and their development prospects. Traditional transfer-of-technology approaches to agricultural research can no longer keep pace with the complex, diverse, risk-prone and dynamic realities of poor farmers. If agricultural research organizations are to be more successful in reducing poverty and increasing the sustainability of agricultural production systems, they must become less isolated, more interconnected and more responsive. In so doing, they must transform themselves into learning organizations, more in touch with field realities and better able to learn and to change. Recent research on the poverty alleviating impacts of technology associated with the Consultative Group on International Agricultural Research (CGIAR) has identified institutional learning and change (ILAC) as a key area for intervention if research is to be more efficient and effective in serving the poor

The effect of a financial crisis on household finances: a case study of Iceland’s financial crisis

Iceland experienced a financial crisis in 2008–2009 when its banking system collapsed, the currency lost half its value, most businesses became technically insolvent, house prices fell, and household debt increased due to indexation to foreign currencies or the price level. This paper tells the story of the crisis and maps the losses to households using a dataset from tax returns that includes all taxpayers in the country and contains the value of housing, mortgage debt, disposable income, and net worth. For relative losses in net worth, the results show that families with children, especially those with parents aged between 24 and 45 years, suffered the largest proportional losses in net worth. The losses were also greater in urban areas. The fall in net worth, measured in local currency, correlated with income and education level as well as the number of children and the urban area. Real disposable income fell by one third or more for a large fraction of the population, causing a further increase in the burden of debt, which increased most for the high-income groups before falling due to rising income and mortgage relief. Urban areas, where banks are located, experienced a boom-bust cycle, while the rural areas experienced this cycle to a much lesser extent. We find that net worth took many years to recover but that by 2019, net worth had recovered for all age groups

Tracing groundwater flow and sources of organic carbon in sandstone aquifers using fluorescence properties of dissolved organic matter (DOM)

The fluorescence properties of groundwaters from sites in two UK aquifers, the Penrith Sandstone of Cumbria and the Sherwood Sandstone of South Yorkshire, were investigated using excitation-emission matrix (EEM) fluorescence spectroscopy. Both aquifers are regionally important sources of public supply water and are locally impacted by anthropogenic pollution. The Penrith Sandstone site is in a rural setting while the Sherwood Sandstone site is in suburban Doncaster. Fluorescence analysis of samples from discrete sample depths in the Penrith Sandstone shows decreasing fulvic-like intensities with depth and also shows a good correlation with CFC-12, an anthropogenic groundwater tracer. Tryptophan- like fluorescence centres in the depth profile may also provide evidence of rapid routing of relatively recent applications of organic slurry along fractures. Fluorescence analysis of groundwater sampled from multi-level piezometers installed within the Sherwood Sandstone aquifer also shows regions of tryptophan-like and relatively higher fulvic-like signatures. The fluorescence intensity profile in the piezometers shows tryptophan-like peaks at depths in excess of 50 metres and mirrors the pattern exhibited by microbial species and CFCs highlighting the deep and rapid penetration of modern recharge due to rapid fracture flow. Fluorescence analysis has allowed the rapid assessment of different types and relative abundances of dissolved organic matter (DOM), and the fingerprinting of different sources of organic carbon within the groundwater system. The tryptophan:fulvic ratios found in the Penrith Sandstone were found to be between (0.5–3.0) and are characteristic of ratios from sheep waste sources. The Sherwood Sandstone has the lowest ratios (0.2–0.4) indicating a different source of DOM, most likely a mixture of terrestrial and microbial sources, although there is little evidence of pollution from leaking urban sewage systems. Results from these two studies suggest that intrinsic fluorescence may be used as a proxy for, or complimentary tool to, other groundwater investigation methods in helping provide a conceptual model of groundwater flow and identifying different sources of DOM within the groundwater system