A cost minimisation analysis in teledermatology: model-based approach

<p>Abstract</p> <p>Background</p> <p>Although store-and-forward teledermatology is increasingly becoming popular, evidence on its effects on efficiency and costs is lacking. The aim of this study, performed in addition to a clustered randomised trial, was to investigate to what extent and under which conditions store-and-forward teledermatology can reduce costs from a societal perspective.</p> <p>Methods</p> <p>A cost minimisation study design (a model based approach) was applied to compare teledermatology and conventional process costs per dermatology patient care episode. Regarding the societal perspective, total mean costs of investment, general practitioner, dermatologists, out-of-pocket expenses and employer costs were calculated. Uncertainty analysis was performed using Monte Carlo simulation with 31 distributions in the used cost model. Scenario analysis was performed using one-way and two-way sensitivity analyses with the following variables: the patient travel distance to physician and dermatologist, the duration of teleconsultation activities, and the proportion of preventable consultations.</p> <p>Results</p> <p>Total mean costs of teledermatology process were €387 (95%CI, 281 to 502.5), while the total mean costs of conventional process costs were €354.0 (95%CI, 228.0 to 484.0). The total mean difference between the processes was €32.5 (95%CI, -29.0 to 74.7). Savings by teledermatology can be achieved if the distance to a dermatologist is larger (> = 75 km) or when more consultations (> = 37%) can be prevented due to teledermatology.</p> <p>Conclusions</p> <p>Teledermatology, when applied to all dermatology referrals, has a probability of 0.11 of being cost saving to society.</p> <p>In order to achieve cost savings by teledermatology, teledermatology should be applied in only those cases with a reasonable probability that a live consultation can be prevented.</p> <p>Trail Registration</p> <p>This study is performed partially based on PERFECT D Trial (Current Controlled Trials No.ISRCTN57478950).</p

Cellular shear adhesion force measurement and simultaneous imaging by atomic force microscope

This paper presents a sensitive and fast cellular shear adhesion force measurement method using an atomic force microscope (AFM). In the work, the AFM was used both as a tool for the imaging of cells on the nano-scale and as a force sensor for the measurement of the shear adhesion force between the cell and the substrate. After the cell imaging, the measurement of cellular shear adhesion forces was made based on the different positions of the cell on the nano-scale. Moreover, different pushing speeds of probe and various locations of cells were used in experiments to study their influences. In this study, the measurement of the cell adhesion in the upper portion of the cell is different from that in the lower portion. It may reveal that the cancer cells have the metastasis tendency after cultured for 16 to 20 hours, which is significant for preventing metastasis in the patients diagnosed with early cancer lesions. Furthermore, the cellular shear adhesion forces of two types of living cancer cells were obtained based on the measurements of AFM cantilever deflections in the torsional and vertical directions. The results demonstrate that the shear adhesion force of cancer cells is twice as much as the same type of cancer cells with TRAIL. The method can also provide a way for the measurement of the cellular shear adhesion force between the cell and the substrate, and for the simultaneous exploration of cells using the AFM imaging and manipulatio

Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review

<p>Abstract</p> <p>Background</p> <p>A major benefit offered by telemedicine is the avoidance of travel, by patients, their carers and health care professionals. Unfortunately, there is very little published information about the extent of avoided travel. We propose to undertake a systematic review of literature which reports credible data on the reductions in travel associated with the use of telemedicine.</p> <p>Method</p> <p>The conventional approach to quantitative synthesis of the results from multiple studies is to conduct a meta analysis. However, too much heterogeneity exists between available studies to allow a meaningful meta analysis of the avoided travel when telemedicine is used across all possible settings. We propose instead to consider all credible evidence on avoided travel through telemedicine by fitting a linear model which takes into account the relevant factors in the circumstances of the studies performed. We propose the use of stepwise multiple regression to identify which factors are significant.</p> <p>Discussion</p> <p>Our proposed approach is illustrated by the example of teledermatology. In a preliminary review of the literature we found 20 studies in which the percentage of avoided travel through telemedicine could be inferred (a total of 5199 patients). The mean percentage avoided travel reported in the 12 store-and-forward studies was 43%. In the 7 real-time studies and in a single study with a hybrid technique, 70% of the patients avoided travel. A simplified model based on the modality of telemedicine employed (i.e. real-time or store and forward) explained 29% of the variance. The use of store and forward teledermatology alone was associated with 43% of avoided travel. The increase in the proportion of patients who avoided travel (25%) when real-time telemedicine was employed was significant (<it>P </it>= 0.014). Service planners can use this information to weigh up the costs and benefits of the two approaches.</p

Study protocol: optimization of complex palliative care at home via telemedicine. A cluster randomized controlled trial

Contains fulltext : 97378.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: Due to the growing number of elderly with advanced chronic conditions, healthcare services will come under increasing pressure. Teleconsultation is an innovative approach to deliver quality of care for palliative patients at home. Quantitative studies assessing the effect of teleconsultation on clinical outcomes are scarce. The aim of this present study is to investigate the effectiveness of teleconsultation in complex palliative homecare. METHODS/DESIGN: During a 2-year recruitment period, GPs are invited to participate in this cluster randomized controlled trial. When a GP refers an eligible patient for the study, the GP is randomized to the intervention group or the control group. Patients in the intervention group have a weekly teleconsultation with a nurse practitioner and/or a physician of the palliative consultation team. The nurse practitioner, in cooperation with the palliative care specialist of the palliative consultation team, advises the GP on treatment policy of the patient. The primary outcome of patient symptom burden is assessed at baseline and weekly using the Edmonton Symptom Assessment Scale (ESAS) and at baseline and every four weeks using the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes are self-perceived burden from informal care (EDIZ), patient experienced continuity of medical care (NCQ), patient and caregiver satisfaction with the teleconsultation (PSQ), the experienced problems and needs in palliative care (PNPC-sv) and the number of hospital admissions. DISCUSSION: This is one of the first randomized controlled trials in palliative telecare. Our data will verify whether telemedicine positively affects palliative homecare. TRIAL REGISTRATION: The Netherlands National Trial Register NTR2817

Leptin Resistance in Vagal Afferent Neurons Inhibits Cholecystokinin Signaling and Satiation in Diet Induced Obese Rats

Background and Aims: The gastrointestinal hormone cholecystokinin (CCK) plays an important role in regulating meal size and duration by activating CCK1 receptors on vagal afferent neurons (VAN). Leptin enhances CCK signaling in VAN via an early growth response 1 (EGR1) dependent pathway thereby increasing their sensitivity to CCK. In response to a chronic ingestion of a high fat diet, VAN develop leptin resistance and the satiating effects of CCK are reduced. We tested the hypothesis that leptin resistance in VAN is responsible for reducing CCK signaling and satiation. Results: Lean Zucker rats sensitive to leptin signaling, significantly reduced their food intake following administration of CCK8S (0.22 nmol/kg, i.p.), while obese Zucker rats, insensitive to leptin, did not. CCK signaling in VAN of obese Zucker rats was reduced, preventing CCK-induced up-regulation of Y2 receptor and down-regulation of melanin concentrating hormone 1 receptor (MCH1R) and cannabinoid receptor (CB1). In VAN from diet-induced obese (DIO) Sprague Dawley rats, previously shown to become leptin resistant, we demonstrated that the reduction in EGR1 expression resulted in decreased sensitivity of VAN to CCK and reduced CCK-induced inhibition of food intake. The lowered sensitivity of VAN to CCK in DIO rats resulted in a decrease in Y2 expression and increased CB1 and MCH1R expression. These effects coincided with the onset of hyperphagia in DIO rats. Conclusions: Leptin signaling in VAN is required for appropriate CCK signaling and satiation. In response to high fat feeding

Physiological characteristics of dysphagia following thermal burn injury

The study aim was to document the acute physiological characteristics of swallowing impairment following thermal burn injury. A series of 19 participants admitted to a specialised burn centre with thermal burn injury were identified with suspected aspiration risk by a clinical swallow examination (CSE) conducted by a speech-language pathologist and referred to the study. Once medically stable, each then underwent more detailed assessment using both a CSE and fiberoptic evaluation of swallowing (FEES). FEES confirmed six individuals (32%) had no aspiration risk and were excluded from further analyses. Of the remaining 13, CSE confirmed that two had specific oral-phase deficits due to orofacial scarring and contractures, and all 13 had generalised oromotor weakness. FEES revealed numerous pharyngeal-phase deficits, with the major findings evident in greater than 50% being impaired secretion management, laryngotracheal edema, delayed swallow initiation, impaired sensation, inadequate movement of structures within the hypopharynx and larynx, and diffuse pharyngeal residue. Penetration and/or aspiration occurred in 83% (n = 10/12) of thin fluids trials, with a lack of response to the penetration/aspiration noted in 50% (n = 6/12 penetration aspiration events) of the cases. Most events occurred post swallow. Findings support the fact that individuals with dysphagia post thermal burn present with multiple risk factors for aspiration that appear predominantly related to generalised weakness and inefficiency and further impacted by edema and sensory impairments. Generalised oromotor weakness and orofacial contractures (when present) impact oral-stage swallow function. This study has identified a range of factors that may contribute to both oral- and pharyngeal-stage dysfunction in this clinical population and has highlighted the importance of using a combination of clinical and instrumental assessments to fully understand the influence of burn injury on oral intake and swallowing

Multinationality and performance literature: a critical review and future research agenda

The literature on the relationship between the degree of multinationality (M) and performance (P) in the context of multinational enterprises (MNEs) has attracted a large volume of research in the past 50 years. Yet, the theoretical foundations and the empirical conclusions concerning the nature of M–P relationship vary greatly, thus call for a critical review and assessment. We examine 135 articles in 39 leading scholarly journals and classic books published during the period 1960–2015. We use an inductive approach and a qualitative content analysis methodology for our comprehensive and critical review of the literature. We incorporate international business, finance, and accounting perspectives in our analysis. We review the conceptualization and measurement of M, P, the findings on M–P relationships, methodologies, and geographic focus. We identify six key inconsistencies in the existing research, which cause ambiguity in the relevant findings. We make eight recommendations for future research to address these inconsistencies. Thus, our study contributes to the central debate in this research field

Seven decades of hydrogeomorphological changes in a near‐natural (Sense River) and a hydropower‐regulated (Sarine River) pre‐Alpine river floodplain in Western Switzerland

This is the peer reviewed version which has been published in final form at https://doi.org/10.1002/esp.5017 . This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.Hydropower alteration of the natural flow and sediment regime can severely degrade hydromorphology, thereby threatening biodiversity and overall ecosystem processes of rivers and their floodplains. Using sequences of aerial images, we quantified seven decades (1938/1942–2013) of spatiotemporal changes in channel and floodplain morphology, as well as changes in the physical habitats, of three floodplain river reaches of the Swiss pre‐Alps, two hydropower‐regulated and one near‐natural. In the Sarine River floodplain, within the first decades of hydropower impairment, the magnitude and frequency of flood events (Q2, Q10, Q30) decreased substantially. As a result, the area of pioneer floodplain habitats that depend on flood activity and sediment dynamic, such as bare sediments, decreased dramatically by approximately 95%. However, by 2013 vegetated areas had generally increased in comparison to the pre‐regulation period in 1943, indicating general vegetative colonization. Between 1943 and 2013, the active channel underwent essential narrowing (up to 62% width reduction in the residual flow reach) and habitat turnover rates were very low (5% of the total floodplain area changed habitat type five to six times). In contrast, from the 1950s onwards, the near‐natural floodplain of the Sense River experienced recurrent narrowing and widening, and frequent changes between bare and vegetated areas, reflecting the shifting habitat mosaic concept typical for natural floodplains. In the three reaches investigated, we found that the active floodplain width and erosion of vegetated areas were primarily controlled by medium to large floods (Q10, Q30), which combined with reduced time intervals between ordinary floods ≥ Q2 most likely mobilized streambed sediments and limited the ability of vegetation to establish itself on bare gravel bars within the parafluvial zone. These findings can contribute to restoration action plans such as controlled flooding and sediment replenishments in the Sarine and other floodplain rivers of the Alps

Major flood disturbance alters river ecosystem evolution

Floods, major formative drivers of channel and floodplain structure and associated riparian and in-stream communities, are increasing in intensity and magnitude with climate change in many regions of the world. However, predicting how floods will affect stream channels and their communities as climate changes is limited by a lack of long-term pre-flood baseline data sets across different organismal groups. Here we show salmon, macroinvertebrate and meiofauna communities, monitored for 30 years in a system evolving owing to glacier retreat, were modified significantly by a major rainfall event that caused substantial geomorphic change to the stream channel. Pink salmon, reduced to one-tenth of pre-flood spawner densities, recovered within two generations. Macroinvertebrate community structure was significantly different after the flood as some pioneer taxa, which had become locally extinct, recolonized whereas some later colonizers were eliminated. The trajectory of the macroinvertebrate succession was reset towards the community structure of 15 years earlier. Meiofaunal abundance recovered rapidly and richness increased post-flood with some previously unrecorded taxa colonizing. Biotic recovery was independent of geomorphological recovery. Markedly different responses according to the organismal group suggest caution is required when applying general aquatic ecosystem theories and concepts to predict flood events